SCHIZOPHRENIA
History of the Concept
Emil Kraepelin first presented his concept of dementia praecox in 1898, emphasizing the progressive intellectual deterioration (dementia) and the early onset (praecox) of the disorder that would come to be known as schizophrenia. Eugen Bleuler focused on the "breaking of associative threads" as the core of the disorder, rather than onset and course. Kraepelin's view led to a narrow definition of schizophrenia; Bleuler's led to a broad one with a much greater theoretical emphasis on "core symptoms."
Bleuler had a great influence on the American conception of schizophrenia, as evidenced by the increased use of the diagnosis. Diagnostic terms such as "schizoaffective psychosis" and "pseudoneurotic schizophrenia" are further examples of the broadened concept. The process-reactive distinction also maintained the broad concept; reactive schizophrenics were said to have a good premorbid history and prognosis, having become psychotic following some life stressor. In contrast, reactive schizophrenia had insidious onset and was thought to indicate some sort of basic physiological malfunction in the brain.
The current DSM-IV definition of schizophrenia narrows the concept in several ways: (1) specific diagnostic criteria are given; (2) patients with symptoms of mood disorder are excluded; (3) the disturbance must last at least six months, excluding those patients with acute psychotic reactions to stress; and (4) mild forms of schizophrenia are now seen as personality disorders.
Three types of schizophrenic disorders in DSM-IV were initially proposed by Kraepelin. Disorganized schizophrenia is characterized by profuse and poorly organized delusions and hallucinations, incoherent speech, disorganized behavior, and neglect of self-care. Catatonic schizophrenia is characterized by motor disturbance and negativism; it is rarely seen today, perhaps because of the success of drug therapy or because previous cases were actually misdiagnoses. Paranoid schizophrenia is the most common type, and includes prominent delusions which are usually persecutory but may be grandiose. Delusional jealousy or ideas of reference also may be present.
Freud once believed that paranoid delusions stemmed from repressed homosexual conflicts, but this once commonly held assumption is, in fact, highly speculative. If anything, repressed homosexual conflicts might play a part in pushing someone "over the edge". Psychoanalysis today sees schizophrenia as a disease that is based in genetic susceptibility and strong environmental factors, especially high expressed negative emotion (see the Karon and Weidner handout).
Definition of schizophrenia
Schizophrenia is a severe form of mental illness affecting about 7 per thousand of the adult population, mostly in the age group 15-35 years. Though the incidence is low (3-10,000), the prevalence is high due to chronicity.
The term schizophrenia was first used in 1911 by Eugen Bleuler, a Swiss psychiatrist, to categorize patients whose thought processes and emotional responses seemed disconnected. The term schizophrenia literally means split mind; however, many people still believe incorrectly that the condition causes a split personality (which is an uncommon problem involving dissociation).
Any of a group of psychotic disorders usually characterized by withdrawal from reality, illogical patterns of thinking, delusions, and hallucinations, and accompanied in varying degrees by other emotional, behavioral, or intellectual disturbances. Schizophrenia is associated with dopamine imbalances in the brain and defects of the frontal lobe and is caused by genetic, other biological, and psychosocial factors.
Facts
• Schizophrenia affects about 24 million people wordwide.
• Schizophrenia is a treatable disorder, treatment being more effective in its initial stages.
• More than 50% of persons with schizophrenia are not receiving appropriate care.
• 90% of people with untreated schizophrenia are in developing countries.
• Care of persons with schizophrenia can be provided at community level, with active family and community involvement.
Etiology of Schizophrenia
1. Regression of Sexual Drive: Freud offers a sexual explanation of this mental disease as of all the others. According to him, the main and fundamental causes of this disease is the regression of sexual energy and the ego towards the stage of the infant, self-love and sucking stage because the patient suffering from it is an adult and yet cannot adjust social responsibility with heterosexual love.
2. Disorganization of Sex Glands: According to Kraepelin, the main cause of schizophrenia is that over-secretion of the sex glands lead to creation of stimulating chemicals in the digestive systems. Not much following is given to this viewpoint.
3. Heredity: Studies of the heredity of such patients have led Kalimann, Stoddard and White among other psychologists, to the belief that its causes are heredity. But Rosanoff believes that along with heredity another important cause is the birth trauma. Presence of heredity does not seem very logical, as its sole cause.
4. Environment: Pollack and Malzberg studied 175 patients of this disease and reached to the conclusion that environment plays a bigger part in creating this disease than does the heredity, and so psychologist today refutes the imPortance of environment in causing of schizophrenia.
5. Biological causes: Adolf Meyer has mentioned biological maladjustment towards the environment as the main cause of schizophrenia to a repression of the life force and to repressed emotional complexes, which is caused by maladjustment with the environment.
6. Instinct for self-respect: According to McDougall, when the patient is unable to find proper and desirable expression for his instincts of self-respect, . he becomes a prey to schizophrenia. Personality type: it is the opinion of some p'sychologist that only a certain personality type is susceptible to schizophrenic tendencies, primarily the introverted type of individual. But this concept of the personality type being more prone to schizophrenia has also not found much of the following among the thinkers of the mark.
7. Conflicts between feminine and masculine elements: According to the neo Freudian Otto Rank, the primary cause of Schizophrenia is the conflict between feminine and masculine elements.
Lastly the apparent primary cause is the individual's disability to adjust with his environment.
Major Types of Schizophrenia
Catatonic schizophrenia - In this case, the person is extremely withdrawn, negative and isolated, and has marked psychomotor disturbances.
Disorganized schizophrenia - In this case the person is verbally incoherent and may have moods and emotions that are not appropriate to the situation. Hallucinations are not usually present.
Paranoid schizophrenia - These persons are very suspicious of others and often have grand schemes of persecution at the root of their behavior. Halluciations and delusions are prominent.
Residual schizophrenia - In this case the person is not currently suffering from delusions, hallucinations, or disorganized speech and behavior, but lacks motivation and interest in day-to-day living.
Schizoaffective disorder - These people have symptoms of schizophrenia as well as mood disorder such as major depression, bipolar mania, or mixed mania.
Signs and Symptoms
Schizophrenia is now used to describe a cluster of symptoms that typically includes the following:
• Delusions.
• Hallucinations.
• Disordered thinking.
• Emotional unresponsiveness.
Because symptoms of schizophrenia arise from various physical processes and respond differently to treatments, some experts recommend classifying the disease based on the presence of the following symptom groups:
• Negative symptoms (including apathy and social withdrawal).
• Psychotic symptoms.
• Disordered thinking. (Some experts group psychotic and disordered thinking in a single category called positive symptoms.)
The disease is complicated by the fact that although a schizophrenic patient may have more than one symptom, he or she rarely has all of them. Symptoms also often go into remission. As the mechanisms in the brain that lead to schizophrenia are being discovered, researchers are attempting to define more accurate ways of describing the disease as it relates to the biologic processes that cause them.
Negative Symptoms
Negative symptoms reflect the following states:
• Diminishment of the self.
• Lack of emotions.
• Colorless speaking tones.
• A general loss of interest in life and the ability to experience pleasure. (One study reported that patients were able to experience unpleasant odors in a normal way, but not pleasant ones.)
• Inappropriate affect (a condition in which the patient displays inappropriate reactions to an event (e.g., laughing hysterically over a loss).
Often certain negative symptoms (e.g., lack of responsiveness and poor sociability) appear in childhood as the first indications of schizophrenia. Certain imaging techniques suggest that these findings are based on biologic changes in specific parts of the brain. In many patients, however, negative symptoms do not appear until after positive symptoms develop. Negative symptoms tend to be more common than positive symptoms in older patients and typically persist after positive symptoms have been treated.
Psychotic Symptoms
Psychotic symptoms, particularly delusions and hallucinations, are the most widely recognized manifestations of schizophrenia.
• Hallucinations. Hallucinations are the experiences of seeing, hearing, tasting, smelling, or feeling things that don't exist. Auditory hallucinations are false senses of sound, such as hearing voices that go unheard by others. They are the most common psychotic symptoms, affecting about 70% of patients. One study even reported that schizophrenic patients who had been profoundly deaf since birth were able to describe convincing experiences of hearing voices.
• Delusions. Delusions are fixed, false beliefs. They can be bizarre (e.g., invisible aliens have entered the room through an electric socket) or nonbizarre (e.g., unwarranted jealousy, or the paranoid belief in being persecuted or watched).
After the initial event, psychotic symptoms usually occur episodically and are interspersed with periods of remission. They typically occur in men between the ages of 17 and 30 and in women between the ages of 20 and 40.
Cognitive Impairment (Disordered Thinking)
The symptoms of cognitive impairment and disordered thinking include the following and may occur before other symptoms of schizophrenia:
• A lack of attention.
• Impaired information processing and an aberrant association between words and ideas. Sometimes this condition is so extreme that speech becomes incoherent and is referred to as "word salad." Patients may connect words because of similarity of sound, rather than by meaning, a condition known as "clang associations."
• Memory impairment. In keeping with other aspects of disordered thinking, memory impairment in schizophrenia is likely to involve the inability to connect an event with its source into a complete and whole memory. For instance, a patient may recall and even feel a familiarity with a specific event but be unable to remember where, when, or how it took place.
• Backward masking dysfunction. This is a trait in which a distraction causes a person to forget a preceding event. It might be an important symptom and a marker of schizophrenia even in people with normal working memories. As an example of a test used to diagnose this trait, the patient is given an item to look at, such as four letters on a computer screen. The screen goes blank and another image called a masking stimulus appears (such as four broken letter fragments). The patient is then asked to type in the original letters. Both symptomatic and presymptomatic patients commonly have problems with this particular exercise.
In summary, people with schizophrenia do poorly on mental tasks requiring conscious awareness, such as verbal fluency, short-term and working memory, and processing speed. However, they are no worse than the general population in underlying (implicit) learning, such as grammar skills, vocabulary, and spatial skills (e.g., map reading). Some experts believe that impaired verbal memory in schizophrenia is a consequence of depression and slowness, but not a result of the disease process.
Other Symptoms
People with schizophrenia may experience other symptoms, such as intolerance of heat (which is associated with antipsychotic medications) and a reduced sense of smell.
Therapies for Schizophrenia
The first line treatment for schizophrenia is usually the use of antipsychotic medication. The newer atypical antipsychotic medication (such as olanzapine, risperidone and clozapine) is preferred over older typical antipsychotic medication (such as chlorpromazine and haloperidol), as the atypicals have different side effect profiles, including less frequent development of extrapyramidal side-effects. However, it is still unclear whether newer drugs reduce the chances of developing the rare but potentially life-threatening neuroleptic malignant syndrome.
Atypical antipsychotics have been claimed to have additional beneficial effects on negative as well as positive symptoms. However, the newer drugs are much more costly as they are still within patent, whereas the older drugs are available in inexpensive generic forms. Aripiprazole a drug from a new class of antipsychotic drugs (variously named 'dopamine system stabilisers' or 'partial dopamine agonists') has recently been developed and early research suggests that it may be a safe and effective treatment for schizophrenia16.
Hospitalisation may occur with severe episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Mental health legislation may also allow a person to be treated against their will. However, in many countries such legislation does not exist, or does not have the power to enforce involuntary hospitalisation or treatment.
Psychotherapy or other forms of talk therapy may be offered, with cognitive behavioural therapy being the most frequently used. This may focus on the direct reduction of the symptoms, or on related aspects, such as issues of self-esteem, social functioning, and insight. There have been some promising results with cognitive behavioural therapy, but the balance of current evidence is inconclusive17.
Other support services may also be available such as drop-in centres, visits from members of a 'community mental health team' and patient-led support groups.
Today, a common belief among most professionals is that the most effective treatment package for schizophrenia probably includes educating the family and patient about current scientific knowledge, working to reduce the stress experienced by the patient on discharge, and encouraging networking among affected families. The integration of biological and psychological interventions is said to be essential; drug treatments are limited by their serious side effects, lack of effect on negative symptoms, lack of improvement in some individuals, and the difficulty of getting patients to continue their medication. But we, in this class, have the luxury of being informed by Bertram Karon’s work, and also the luxury of not being in the current psychiatric political arena where he is routinely discarded. The tragedy is that he is not given credence unless he is directly heard. Also, the type of treatment that he can and does do is an art Unfortunately most can not work with his insight and gentleness. And the vast majority of the schizophrenic population languishes on in a drugged stupor.
REHABILITATION
Medical Care
Medication
Whereas drugs are not usually thought of as rehabilitation, antipsychotic medication is the mainstay of maintenance treatment for schizophrenia. It is through the use of these medications that symptoms such as hallucinations, delusions, thought disorder and bizarre-appearing behaviour will be controlled. Once these symptoms are controlled, a major source of preoccupation for the patients is removed. This in turn allows patients to focus attention on other aspects of their life. Without medication, between 75% - 80% of patients will have acute symptoms of schizophrenia recur within two years. Despite the paramount importance of medication, it is far from the only form of continuing treatment required for somebody suffering from schizophrenia. Many aspects of living in society must be considered when developing programs to help patients overcome deficits in their functioning and acquire new skills.
Medical Follow-up
Medical follow-up is part of rehabilitation. The need for follow-up is two-fold. First, to ensure that the patient has sufficient medication(s) to keep his major symptoms under control and, second, to ensure that the patient's medications are raised or lowered depending on his progress. The intention is to maintain a person on the lowest therapeutic dose of medication possible. Almost invariably, the dose of medication on discharge from hospital is higher than will be required later. However, the lowest dose possible can only be achieved over time with small reductions every 3 - 6 months, depending on the individual. Should major symptoms return while the patient's medication is being reduced, this will be noticed and corrected if he is attending his doctor regularly. A slightly higher dose of medication will ensure that the symptoms are once again controlled, thus avoiding the need for further hospitalization. This, of course, involves the co-operation of the patient and physician primarily but it is hoped that the patient's family and friends can also be involved.
Hospitalization
Hospitalization, mainly in the form of crisis intervention, is an integral part of a rehabilitation program. Patients and families (and therapists) must have ready access to emergency wards, crisis units, day units, and occasionally, to longer stay beds. Knowing they are available lessens anxiety and may make their use less imperative.
Psychotherapy
Supportive psychotherapy is a cornerstone of the rehabilitation program. The individual meets with his therapist to discuss any concerns he may have about any aspect of his life. Medications are frequently a concern and much time will need to be given to the discussion about why they are used, how they work, their side-effects, and how to cope with side-effects. Other issues for which patients frequently seek advice include: housing, vocational issues, leisure time, and quality of life. Obtaining social services, including money, transport, allowances, etc., is also a frequent cause of concern. Supportive psychotherapy gives the patient an opportunity to review his options in any situation. The therapist may be called upon to assist in making a decision. On occasions it may be necessary for the therapist to recommend one approach over others. In other words the therapist may be more direct and act in a more advisory capacity than if he were counselling less ill patients. Self-questioning to do with "why me?" may also arise along with other existential questions which require airing and discussion.
Psychotherapy Treatment Methods
Psychotherapy may occur on an individual basis, where the patient and therapist or therapists meet together to discuss a specific problem and attempt to solve it. Psychotherapy also takes place in group settings. There are primarily two types of group settings. Groups can be intended for discussion and focussed problem solving, or they may be designed to be more open and less intensive. Social groups are an example of the latter. Who should be involved in which approach is determined by the patient and his ability to participate, as well as by the availability of such services.
Alcohol and Street Drugs
Intervention programs for alcohol and drug abuse are part of rehabilitation. Excessive and continuous substance abuse may increase the intensity of psychotic symptoms hallucinations, delusions, thought disorder) and cause the patient additional problems.
The problem of substance abuse is a common one in schizophrenia and must be confronted by exploration, education, supervision, monitoring and peer discussion. Behavioural techniques and supportive psychotherapy will be effective as will family involvement and, sometimes, referral to special drug and alcohol programs.
Entitlements
In the best of all possible worlds, every person is entitled to continuous, comprehensive and co-ordinated care as well as consistent financial resources to meet basic needs such as shelter, food, clothing and spending money. Personal care needs such as hygiene, personal safety, medical care, and mobility need to be looked after. Psycho-social needs, not often thought of as entitlements include: interpersonal relationships, emotional support, meaningful daily recreational and vocational activities, respectful treatment, consideration, unrushed psychotherapeutic help and community hospitality. Such needs must be met before a person can develop a sense of well-being. It is the responsibility of the treatment team/therapists to educate the person suffering from schizophrenia about these entitlements and to assist in obtaining them as fully as possible.
It is important that families and significant others know about the basic requirements needed to achieve a better quality of life.
Finances
It is very important to be sensitive to the financial needs of the individual. If basic living activities such as shelter, food, clothing, transport, social and recreational activities are overlooked, unnecessary unwanted outcomes may result, e.g., sleeping on the street, begging, relapses, imprisonments, medical problems, etc.
Money is usually available from a variety of sources: wages or salary from full-time or casual work, disability payments, welfare, workman's compensation, unemployment insurance, money from relatives/friends, including inheritances and trust funds.
To discover who is eligible for what benefits is best done by consulting with your local social worker. There are assistance plans run by various levels of government: Municipal or Local, Provincial (or State), Federal. Additional subsidies may also be available for rent, transport, food and clothing. Emergency funds are also usually available for genuine emergencies.
Whatever the situation, every attempt should be made to assist the individual to obtain the maximum amount of financial benefits. Even with maximum benefits, many patients live below the poverty line, spending all their income on accommodation and food with little or nothing left for transport and pocket money.
Many families find it humiliating to ask for government support. It is important to keep in mind that the patient frequently finds it less humiliating to accept government money than to take money from parents.
Budgeting
Some people experience great difficulty in managing their money, for others this is not an issue - they budget very well. For those who experience difficulty, money may become a major concern - there is a tendency to spend all the money at once, leaving essential bills unpaid. This may lead to borrowing from relatives, friends or begging, and at times, even to petty theft.
These problems can most practically be overcome by education about budgeting and helping the person learn how to manage his money responsibly. This requires patience, plus direction in banking, assistance with shopping and budgeting patterns, visits to the local grocery store, talks from nutritionists, budget lists or guidelines, etc. For example, milk can be suggested instead of soft drinks, and so on. The individual is familiarized periodically with low-cost food, clothing and basic essentials that are "on special". Since many patients eat in restaurants, they need to be advised about low-cost places that offer a balanced diet. For crises, many communities have emergency food centres and food vouchers.
The individual needs to be assisted in keeping a sense of perspective in deciding how to spend weekly allowances, pay expenses, maintain a small savings account. Some individuals with severe spending difficulty need to be discouraged from the use of cheques, credit cards and frequent crediting at the local corner store.
If money mismanagement persists, some government offices such as the Public Trustee may be involved on a voluntary basis by the patient, or on an involuntary basis if the patient is judged financially incompetent. However, such a move may cost the patient a fee.
It is crucial to assist the individual with schizophrenia to assess changing financial needs and potential resources for managing finances. Rewards and incentives work well. (For instance, vouchers, tickets to a play, movie or sports event.) Adequate financial help and budgeting promote independence.
Housing
Where should the individual suffering from schizophrenia live? In the family home, foster home, boarding home, nursing home, apartment, rooming house or residential setting? The right answer depends on the individual's needs and available housing. The individual's requirements must first be assessed before housing options can be explored.
When selecting a setting, consider the following issues: what kind of setting is required? How much supervision is required? Can the person care for himself? The presenting deficits will determine how much support will be required. Daily supervision may be required for some patients.
Not every patient will need extensive support. He may only need supervision for taking medication or help in the constructive use of leisure time or the development of useful social activities. In such cases, housing which provides once a week supervision may be sufficient.
What happens if the patient is noisy, violent, refusing treatment, smoking up or stealing in the house? Such problems need to be dealt with on an individual basis depending upon the situation, the reasons for the behaviour and the stage of illness. The responsible party must not be rejected or abandoned. A crisis requires helpful intervention. At the same time, it is important to make clear the expectations of the household and the consequences of not meeting them. If skills required for daily living are lacking, they can be learned. If the law is being broken, the police may have to be involved.
Nutrition
What is the best diet for people with schizophrenia? Some individuals with schizophrenia adopt a monotonous diet, eating the same food daily, gaining very little pleasure from taste, or attractive preparation of a meal, snacking on potato chips, chocolate bars and candies. Even worse, they don't eat enough. This may occur when they are actively psychotic, fearing their food is poisoned.
Limited and poor nutritional intake is of concern to clinicians and relatives. We all need good food and a balanced diet. This keeps our weight under control and will likely benefit other medical conditions such as blood pressure, diabetes, dental problems, and constipation, among others.
To ensure that isolated patients have access to food, daycare/aftercare programs often provide nourishing snacks to groups, e.g., green vegetables, cheese, milk, juice, water, fruits, sandwiches etc. At the same time, it is wisest to serve no stimulants such as coffee, tea, cocoa, or soft drinks. Learning shopping and cooking skills is also encouraged. In cases of emergency, most communities have some sort of food bank where patients can be referred for free groceries.
Avocational
Living Skills
Living skills are the activities of everyday life: how to say hello, how to shop, cook, take a bus and the like. People with schizophrenia may have to learn or relearn how to do many of these so they can return to competent functioning. In recent years, a number of centres have been developing programs to teach living skills.
First, a decision must be made about what new skills are needed, then an individualized program for that person needs to be developed. For example, Bing is a 30 year old man who has just been discharged from hospital for the 5th time in one year. He is unsure of himself, worried about his new rooming house, and lacks the initiative to start a conversation. He also has very limited money, clothing and few relatives or friends in the city. However, he has some contact with the local clergy.
A Plan to Help
Help for Bing could include: a visit with him to get acquainted with his new residence, a meeting with his new landlord, an offer of support and assistance during crisis. Bing needs to learn social skills; grooming, hygiene, cleaning and decorating his room, obeying house rules, doing laundry, ironing etc. A worthwhile endeavour might be a walk through the neighbourhood, noting the local variety store and introducing Bing to the owners, a walk to the park, taking notice of low cost clothing and food stores. It is important to also note social agencies, workshops, welfare office, emergency shelter, distress phone number, drop-in or recreation centre or local YMCA or gym facility. This can be followed by weekly home visits to see how comfortable Bing feels with his surroundings and how self-assured he becomes in managing social skills. It is important to be available for crisis management and consultation with landlords and other community workers and the clergy.
For any skill Bing is uncertain about, a step-by-step routine can be developed and then demonstrated. Then Bing can do it himself with and without supervision until he is comfortable and knows how to do it well.
Transportation
Transportation is very important as most patients have to travel distances too great to walk. Can individuals afford to get to treatment? It is crucial to keep this in mind and assist the person as much as possible with necessary benefits, e.g. bus tickets, passes, vouchers.
Can the person use the transit system? Often patients may be afraid to mention their fear of the subway escalators or crowds. This may make the difference between attending a program, job or recreation, or dropping out.
Use of Leisure
Most people who have been ill with schizophrenia are not well off financially and find it hard to know what to do with all the time on their hands. This is perhaps the most important area for constructive rehabilitation - how to help the person who is neither working nor at school to use his time creatively and rewardingly.
It is very useful for rehabilitation programs to be aware of local activities which are not expensive. This will include activities at community centres, athletic centres, libraries, churches, mosques and synagogues, art galleries, museums, parks and recreation centres, universities and colleges and adult education centres as well as community services especially designed for the disabled. Shopping malls, large hotels, art exhibits, skating rinks, swimming pools, pool halls, public gardens, and gardening centres constitute arenas of activities that can be participated in or observed with enjoyment. Crowds may not be welcomed by the patient so the timing of outings may need to be adjusted to coincide with times of lesser traffic. Bridge clubs, stamp clubs, chess clubs are usually of interest, as may be bingo halls, science exhibits, bands, concerts, animal shows and zoos. Big cities may have special drop in centres and other activities for ex-psychiatric patients.
Although socializing is difficult, many ex-patients would like to have opportunities to make friends, especially with members of the opposite sex. Church dances or park concerts may serve that purpose. Specialized social functions for ex-psychiatric patients exist in some communities as do various social-recreational day programs with a focus on group interaction and activity.
For very shy individuals, visiting nurses, members of the family or church organizations, volunteers or others may be available to come to the home and accompany clients to outside functions.
Many people with schizophrenia spend long hours watching television. Although this may be an invaluable distraction, as may be reading or listening to music, these activities have two disadvantages. They are sedentary and solitary. Schizophrenics opt for aloneness frequently and need to be able to retire to privacy when they wish to but some parts of their day need to be among others and active. Exercise and athletic activities need to be promoted.
Shopping, cooking, cleaning, mending may be solitary activities but they are purposeful and leave the doer with a sense of accomplishment. As such, they also need to be promoted.
Talking on the phone with friends is important for continuing contacts which may be difficult to keep up in person.
The provision of telephone services and postal services for the person with schizophrenia is very important.
Spiritual counselling is vital for individuals who have had serious health problems and who continue to lead difficult lives. Meaning is crucial in all lives, perhaps especially so for the psychiatrically ill.
Opportunities for creative outlets - music, art, writing, crafts - are also of great importance. It has been postulated that creativity and schizophrenia are linked in some way. It is certainly true that many schizophrenic individuals are exceptionally creative and feel better if creative urges can be expressed. Keeping a diary is often perceived as meaningful and creative.
Travel often costs too much but when it can be afforded, it offers a change of pace and scenery and a break from routine that is long remembered. Trips need to be carefully planned and organized but form an important part of a comprehensive rehabilitation program.
Some schizophrenics are parents and need to occupy not only themselves but also their children. This is a big responsibility for which they may be ill-prepared and insufficiently supported. Rehabilitation programs need to offer opportunities for parental guidance and skill training as well as to provide baby-sitting arrangements to relieve parents. The health, education and social needs of the children must be attended to as well as the marital and family counselling needs of the parent
Fitness and Exercise
Physical fitness is important to help maintain a sense of well-being. It also helps the individual to function more efficiently. Another important point is that fitness and exercise offer a different focus for people with uncomfortable feelings due to fear, tension and anxiety. There are many ways to achieve fitness.
Types of exercise include: brisk walking, running, stair climbing, dancing, hiking, cycling, swimming, sports volleyball, hockey, baseball, etc.
Potential sites are: local gyms, YMCA, health spas, recreational facilities, day centres, residential settings. The environment should be comfortable and supporting.
Timing: The establishment of a routine is important - morning, lunch, afternoon. It is well to start with small workouts and to increase the duration gradually.
Individuals with schizophrenia should be encouraged to get plenty of moderate exercise daily. A medical check-up is advisable before starting any program. To promote fitness and exercise habits, rewards and incentives, (e.g. tickets to the ball game, movies, exercise outfits, vouchers to fitness clubs) work well.
Vocational Rehabilitation
Employment
Rehabilitation has always been understood to include assistance in job training and job finding. The majority of those with schizophrenia will not, however, do well with traditional vocational rehabilitation. The same difficulties that interfere with keeping jobs (problems in keeping regular hours, slowness, anxieties in dealing with other people, misinterpretation of the motives of others, dissatisfaction with the relative lack of challenge offered by the job or its relatively low pay, feelings of being taken advantage of, inability to make friends on the job, inappropriate dress or behaviour, irrational fears of job related circumstances, inability to cope with authority, with demands, deadlines and evaluations) may also interfere with regular vocational rehabilitation programs which may present the very same obstacles. Special programs which recognize the schizophrenic client's special vulnerabilities are helpful. Flexibility of hours, provision of privacy, anticipation of problems, establishment of an anxiety-free routine all help. Job goals should probably be minimal if the above problems predominate, with a focus, instead, on meaningful activities outside of employment.
For instance, the highly intelligent, sensitive schizophrenic may feel it below his dignity to be training for a job as office help. If the job is seen, however, as part-time, solely for the purpose of making a living and if stress is put on the creative and intellectual potential of evenings and weekends, efforts at job training may be successful.
Many communities have special employment incentives for the ill and disabled and these should be investigated. Psychiatric disability may be invisible (in distinction to individuals who are blind or crippled or hard of hearing) but qualify for special opportunities for the disabled nonetheless.
Each geographic area has its own opportunities. Big cities have more special programs but rural communities may offer more of the kind of work that people with schizophrenia enjoy: slower paced, less crowded, involving nature or animals or children.
Helping others is frequently an activity to which individuals with schizophrenia aspire. The skills and grades required to enter medicine or social work may be impossible but volunteer work is frequently available.
This kind of work does not pay financially but provides the recovering schizophrenic with a sense of purpose and meaning.
Volunteering is an art in itself and it requires skillful and knowledgeable leadership to link potential volunteers with appropriate posts.
A point to keep in mind for families is the importance of valuing whatever the recovering patient spends his time at. The work may be monotonous, ill-paid, repetitious, unchallenging but it provides for the worker a social and occupational niche, an eventually familiar and safe environment, a structured routine, and a diversion from sometimes unpleasant preoccupations. If there is a pay cheque associated with it, so much the better. If there is a sense of meaning or worth to the work, better still.
Retraining
After an illness like schizophrenia, many individuals want to go back to school, either to finish something they had started or to train for something new. Often academic studies are abandoned in favour of something that can be done "with the hands." This is because manual occupations usually involve less interpersonal interaction. Training for work that can be done in relative isolation or during hours when few others are around is often a good idea. Seasonal work is also attractive as it allows for periods of hibernation.
Some individuals with schizophrenia go back to school simply because they enjoy studying, not with a view to graduating. They are intellectually curious and enjoy taking courses and are happy to do so indefinitely. For some, exams and classroom competition may be difficult so it is wise to select courses that do not necessitate exposure to such stresses.
Courses where a certain amount of eccentricity is the norm (art, music, chess, poetry) in class may be the most comfortable ones for people with schizophrenia to attend because they may feel more anonymous and safe. Some prefer correspondence courses which entail the least interpersonal contact.
Education
Education About Illness
Patients need to learn about their illness and how to cope with it. For example, they need to know about the illness, its treatment, side-effects, and what community programs are available to assist them in their recovery from the illness. Depending on the size of the community involved, there may exist organized and systematic rehabilitation programs. Even in small communities, however, through taking special initiatives, therapists and families have been able to develop informal programs that have been extremely useful to their relatives. Once a need has been outlined, some form of program or activity can be developed to answer that specific need. It is important that all concerned in the care of the patient be informed as to what is available by way of formal programming. Social workers and occupational therapists are usually the people to talk to about such issues. There may also be community agencies that are specifically set up to provide information about what is available. This is particularly true in larger cities where the number of programs may be so varied that it is impossible for any one individual to keep pace with them all. In smaller communities, programs may need to be developed and this will mean that all members of the community may have to pull together to solve the problem. For example, local business people, church groups, or other charitable organizations may be quite willing to provide some aspects of what might be required for an individual to expand his functioning. The important point here is that lack of specific formal programs should not be viewed as an insurmountable obstacle in the management of the person suffering from schizophrenia.
Family Support and Education
With any longterm illness the patient must rely heavily on the support of his family, friends, and community in general to assist him in continuing as normal a life as possible. With schizophrenia the situation is no different. Families are thrust into the role of being primary caregivers, whether they realize it or not. Initially, when the illness begins, virtually no family is equipped to cope with it. Over time, with education about the illness and support in matters of management and coping, the hope is that the family or primary care-givers will themselves learn how to care for their ill relative. Most cannot do this alone, hence it becomes vitally important that they have the same access to community facilities that physicians and other therapists expect. Unfortunately, such open access to community resources is rarely available to families.
Families need to know whom they can call upon should they need help. Initially this will mean being aware of who the patient's doctor is, what nurses, occupational therapists, social workers, psychologists etc. are involved in their relative's care. They need to know what community agencies their relative is expected to attend, and whether or not there are any volunteers who might be available to assist them in the care and management of their relative, particularly if he or she is severely disabled. Volunteers can come from all walks of life including people totally unknown to and unrelated to the patient's family, neighbours, landlords, and so on. Frequently families may experience a sense of guilt or loss of status because of the fact that their family member is suffering from schizophrenia. This often makes families reluctant to talk about illness in their relative. However, it is frequently the case that when the family decides to discuss the problem more openly they are quickly approached by others in the community who confess to having the same affliction in their own family.
Such peer support for families is extremely valuable but its usefulness has been overlooked in the past. This is changing and many organizations have been set up to help the relatives contact each other.
The Law
The person with schizophrenia, as well as family members, during the rehabilitation period may find themselves for the first time in their lives involved with the law. This may occur for a variety of reasons.
Minor Offenses
Schizophrenia may lead to disinhibition or social inappropriateness and may involve the individual in public disturbances, in behaviour perceived as offensive, violent or harassing, or in conduct perceived as sexually provocative. Acts of threatened suicide or responses to delusional or hallucinatory stimuli may lead to arrest and legal consequence. It may also happen that the schizophrenic is a victim of violence, theft or sexual assault. He or she may require legal representation to deal with landlords, neighbours or shopowners who accuse him of disturbance. Easy access to legal aid is an indispensable part of an adequate rehabilitation service.
Hospital and Treatment Issues
Legal representation (for patient and family) must also be available to deal with issues of involuntary hospitalization, matters of financial competence during times of acute recurrence of symptoms, guardianship, consent to treatment, access to medical records and, in academic settings, consent in relation to teaching and research. Mental health legislation differs from jurisdiction to jurisdiction and periodically changes. Patients and families, as well as treatment providers, need to be thoroughly familiar with procedures that are required under the law.
For instance, the issue that gives most trouble to most families, is how to arrange treatment for a relative who "is getting sick again" but who does not realize it and who steadfastly refuses a psychiatric assessment. Under the law of most jurisdictions no one (family, doctors, police included) can legally impose assessment unless the person in question is perceived as dangerous, either to himself or to others. Potential dangerousness (by word or action) needs to be carefully documented before the person can be brought to a hospital emergency room for psychiatric assessment against his will. This is a difficult problem for many families and needs to be understood and anticipated, with clear plans made on how family members and treatment providers can best diffuse these situations before they arise.
For example, in situations where violence has been a particular problem, some families have found it helpful to know the local police, their intention being to ensure that the police understand the situation and know what the most helpful actions are in advance of any crisis.
Forensic Psychiatry
Psychiatric patients who commit criminal offenses may be given prison terms or may be admitted to forensic psychiatry treatment units. A different set of laws are operative in that case and, again, legal consultation may be necessary. It is important for the prosecuting attorney and the judge to understand the nature of the offender's illness.
Trust Funds and Wills
Families are frequently concerned about the convalescing schizophrenic's ability to budget appropriately. They may need legal advice on how to help safeguard their relative's financial status. In particular, they worry about what will happen to their schizophrenic son or daughter once they are gone. Legal and financial assistance will be required to draw up appropriate wills and trust funds in order to ensure a safe environment and a satisfying life for their disabled relative.
Prognosis
Prognosis for any particular individual affected by schizophrenia is particularly hard to judge as treatment and access to treatment is continually changing as new methods become available and medical recommendations change.
However, retrospective studies have shown that about a third of people make a full recovery, about a third show improvement but not a full recovery, and a third remain ill19.
There is an extremely high suicide rate associated with schizophrenia. A recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime20. Another study suggested that 10% of persons with schizophrenia die by suicide21
SCHIZOPHRENIA
History of the Concept
Emil Kraepelin first presented his concept of dementia praecox in 1898, emphasizing the progressive intellectual deterioration (dementia) and the early onset (praecox) of the disorder that would come to be known as schizophrenia. Eugen Bleuler focused on the "breaking of associative threads" as the core of the disorder, rather than onset and course. Kraepelin's view led to a narrow definition of schizophrenia; Bleuler's led to a broad one with a much greater theoretical emphasis on "core symptoms."
Bleuler had a great influence on the American conception of schizophrenia, as evidenced by the increased use of the diagnosis. Diagnostic terms such as "schizoaffective psychosis" and "pseudoneurotic schizophrenia" are further examples of the broadened concept. The process-reactive distinction also maintained the broad concept; reactive schizophrenics were said to have a good premorbid history and prognosis, having become psychotic following some life stressor. In contrast, reactive schizophrenia had insidious onset and was thought to indicate some sort of basic physiological malfunction in the brain.
The current DSM-IV definition of schizophrenia narrows the concept in several ways: (1) specific diagnostic criteria are given; (2) patients with symptoms of mood disorder are excluded; (3) the disturbance must last at least six months, excluding those patients with acute psychotic reactions to stress; and (4) mild forms of schizophrenia are now seen as personality disorders.
Three types of schizophrenic disorders in DSM-IV were initially proposed by Kraepelin. Disorganized schizophrenia is characterized by profuse and poorly organized delusions and hallucinations, incoherent speech, disorganized behavior, and neglect of self-care. Catatonic schizophrenia is characterized by motor disturbance and negativism; it is rarely seen today, perhaps because of the success of drug therapy or because previous cases were actually misdiagnoses. Paranoid schizophrenia is the most common type, and includes prominent delusions which are usually persecutory but may be grandiose. Delusional jealousy or ideas of reference also may be present.
Freud once believed that paranoid delusions stemmed from repressed homosexual conflicts, but this once commonly held assumption is, in fact, highly speculative. If anything, repressed homosexual conflicts might play a part in pushing someone "over the edge". Psychoanalysis today sees schizophrenia as a disease that is based in genetic susceptibility and strong environmental factors, especially high expressed negative emotion (see the Karon and Weidner handout).
Definition of schizophrenia
Schizophrenia is a severe form of mental illness affecting about 7 per thousand of the adult population, mostly in the age group 15-35 years. Though the incidence is low (3-10,000), the prevalence is high due to chronicity.
The term schizophrenia was first used in 1911 by Eugen Bleuler, a Swiss psychiatrist, to categorize patients whose thought processes and emotional responses seemed disconnected. The term schizophrenia literally means split mind; however, many people still believe incorrectly that the condition causes a split personality (which is an uncommon problem involving dissociation).
Any of a group of psychotic disorders usually characterized by withdrawal from reality, illogical patterns of thinking, delusions, and hallucinations, and accompanied in varying degrees by other emotional, behavioral, or intellectual disturbances. Schizophrenia is associated with dopamine imbalances in the brain and defects of the frontal lobe and is caused by genetic, other biological, and psychosocial factors.
Facts
• Schizophrenia affects about 24 million people wordwide.
• Schizophrenia is a treatable disorder, treatment being more effective in its initial stages.
• More than 50% of persons with schizophrenia are not receiving appropriate care.
• 90% of people with untreated schizophrenia are in developing countries.
• Care of persons with schizophrenia can be provided at community level, with active family and community involvement.
Etiology of Schizophrenia
1. Regression of Sexual Drive: Freud offers a sexual explanation of this mental disease as of all the others. According to him, the main and fundamental causes of this disease is the regression of sexual energy and the ego towards the stage of the infant, self-love and sucking stage because the patient suffering from it is an adult and yet cannot adjust social responsibility with heterosexual love.
2. Disorganization of Sex Glands: According to Kraepelin, the main cause of schizophrenia is that over-secretion of the sex glands lead to creation of stimulating chemicals in the digestive systems. Not much following is given to this viewpoint.
3. Heredity: Studies of the heredity of such patients have led Kalimann, Stoddard and White among other psychologists, to the belief that its causes are heredity. But Rosanoff believes that along with heredity another important cause is the birth trauma. Presence of heredity does not seem very logical, as its sole cause.
4. Environment: Pollack and Malzberg studied 175 patients of this disease and reached to the conclusion that environment plays a bigger part in creating this disease than does the heredity, and so psychologist today refutes the imPortance of environment in causing of schizophrenia.
5. Biological causes: Adolf Meyer has mentioned biological maladjustment towards the environment as the main cause of schizophrenia to a repression of the life force and to repressed emotional complexes, which is caused by maladjustment with the environment.
6. Instinct for self-respect: According to McDougall, when the patient is unable to find proper and desirable expression for his instincts of self-respect, . he becomes a prey to schizophrenia. Personality type: it is the opinion of some p'sychologist that only a certain personality type is susceptible to schizophrenic tendencies, primarily the introverted type of individual. But this concept of the personality type being more prone to schizophrenia has also not found much of the following among the thinkers of the mark.
7. Conflicts between feminine and masculine elements: According to the neo Freudian Otto Rank, the primary cause of Schizophrenia is the conflict between feminine and masculine elements.
Lastly the apparent primary cause is the individual's disability to adjust with his environment.
Major Types of Schizophrenia
Catatonic schizophrenia - In this case, the person is extremely withdrawn, negative and isolated, and has marked psychomotor disturbances.
Disorganized schizophrenia - In this case the person is verbally incoherent and may have moods and emotions that are not appropriate to the situation. Hallucinations are not usually present.
Paranoid schizophrenia - These persons are very suspicious of others and often have grand schemes of persecution at the root of their behavior. Halluciations and delusions are prominent.
Residual schizophrenia - In this case the person is not currently suffering from delusions, hallucinations, or disorganized speech and behavior, but lacks motivation and interest in day-to-day living.
Schizoaffective disorder - These people have symptoms of schizophrenia as well as mood disorder such as major depression, bipolar mania, or mixed mania.
Signs and Symptoms
Schizophrenia is now used to describe a cluster of symptoms that typically includes the following:
• Delusions.
• Hallucinations.
• Disordered thinking.
• Emotional unresponsiveness.
Because symptoms of schizophrenia arise from various physical processes and respond differently to treatments, some experts recommend classifying the disease based on the presence of the following symptom groups:
• Negative symptoms (including apathy and social withdrawal).
• Psychotic symptoms.
• Disordered thinking. (Some experts group psychotic and disordered thinking in a single category called positive symptoms.)
The disease is complicated by the fact that although a schizophrenic patient may have more than one symptom, he or she rarely has all of them. Symptoms also often go into remission. As the mechanisms in the brain that lead to schizophrenia are being discovered, researchers are attempting to define more accurate ways of describing the disease as it relates to the biologic processes that cause them.
Negative Symptoms
Negative symptoms reflect the following states:
• Diminishment of the self.
• Lack of emotions.
• Colorless speaking tones.
• A general loss of interest in life and the ability to experience pleasure. (One study reported that patients were able to experience unpleasant odors in a normal way, but not pleasant ones.)
• Inappropriate affect (a condition in which the patient displays inappropriate reactions to an event (e.g., laughing hysterically over a loss).
Often certain negative symptoms (e.g., lack of responsiveness and poor sociability) appear in childhood as the first indications of schizophrenia. Certain imaging techniques suggest that these findings are based on biologic changes in specific parts of the brain. In many patients, however, negative symptoms do not appear until after positive symptoms develop. Negative symptoms tend to be more common than positive symptoms in older patients and typically persist after positive symptoms have been treated.
Psychotic Symptoms
Psychotic symptoms, particularly delusions and hallucinations, are the most widely recognized manifestations of schizophrenia.
• Hallucinations. Hallucinations are the experiences of seeing, hearing, tasting, smelling, or feeling things that don't exist. Auditory hallucinations are false senses of sound, such as hearing voices that go unheard by others. They are the most common psychotic symptoms, affecting about 70% of patients. One study even reported that schizophrenic patients who had been profoundly deaf since birth were able to describe convincing experiences of hearing voices.
• Delusions. Delusions are fixed, false beliefs. They can be bizarre (e.g., invisible aliens have entered the room through an electric socket) or nonbizarre (e.g., unwarranted jealousy, or the paranoid belief in being persecuted or watched).
After the initial event, psychotic symptoms usually occur episodically and are interspersed with periods of remission. They typically occur in men between the ages of 17 and 30 and in women between the ages of 20 and 40.
Cognitive Impairment (Disordered Thinking)
The symptoms of cognitive impairment and disordered thinking include the following and may occur before other symptoms of schizophrenia:
• A lack of attention.
• Impaired information processing and an aberrant association between words and ideas. Sometimes this condition is so extreme that speech becomes incoherent and is referred to as "word salad." Patients may connect words because of similarity of sound, rather than by meaning, a condition known as "clang associations."
• Memory impairment. In keeping with other aspects of disordered thinking, memory impairment in schizophrenia is likely to involve the inability to connect an event with its source into a complete and whole memory. For instance, a patient may recall and even feel a familiarity with a specific event but be unable to remember where, when, or how it took place.
• Backward masking dysfunction. This is a trait in which a distraction causes a person to forget a preceding event. It might be an important symptom and a marker of schizophrenia even in people with normal working memories. As an example of a test used to diagnose this trait, the patient is given an item to look at, such as four letters on a computer screen. The screen goes blank and another image called a masking stimulus appears (such as four broken letter fragments). The patient is then asked to type in the original letters. Both symptomatic and presymptomatic patients commonly have problems with this particular exercise.
In summary, people with schizophrenia do poorly on mental tasks requiring conscious awareness, such as verbal fluency, short-term and working memory, and processing speed. However, they are no worse than the general population in underlying (implicit) learning, such as grammar skills, vocabulary, and spatial skills (e.g., map reading). Some experts believe that impaired verbal memory in schizophrenia is a consequence of depression and slowness, but not a result of the disease process.
Other Symptoms
People with schizophrenia may experience other symptoms, such as intolerance of heat (which is associated with antipsychotic medications) and a reduced sense of smell.
Therapies for Schizophrenia
The first line treatment for schizophrenia is usually the use of antipsychotic medication. The newer atypical antipsychotic medication (such as olanzapine, risperidone and clozapine) is preferred over older typical antipsychotic medication (such as chlorpromazine and haloperidol), as the atypicals have different side effect profiles, including less frequent development of extrapyramidal side-effects. However, it is still unclear whether newer drugs reduce the chances of developing the rare but potentially life-threatening neuroleptic malignant syndrome.
Atypical antipsychotics have been claimed to have additional beneficial effects on negative as well as positive symptoms. However, the newer drugs are much more costly as they are still within patent, whereas the older drugs are available in inexpensive generic forms. Aripiprazole a drug from a new class of antipsychotic drugs (variously named 'dopamine system stabilisers' or 'partial dopamine agonists') has recently been developed and early research suggests that it may be a safe and effective treatment for schizophrenia16.
Hospitalisation may occur with severe episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Mental health legislation may also allow a person to be treated against their will. However, in many countries such legislation does not exist, or does not have the power to enforce involuntary hospitalisation or treatment.
Psychotherapy or other forms of talk therapy may be offered, with cognitive behavioural therapy being the most frequently used. This may focus on the direct reduction of the symptoms, or on related aspects, such as issues of self-esteem, social functioning, and insight. There have been some promising results with cognitive behavioural therapy, but the balance of current evidence is inconclusive17.
Other support services may also be available such as drop-in centres, visits from members of a 'community mental health team' and patient-led support groups.
Today, a common belief among most professionals is that the most effective treatment package for schizophrenia probably includes educating the family and patient about current scientific knowledge, working to reduce the stress experienced by the patient on discharge, and encouraging networking among affected families. The integration of biological and psychological interventions is said to be essential; drug treatments are limited by their serious side effects, lack of effect on negative symptoms, lack of improvement in some individuals, and the difficulty of getting patients to continue their medication. But we, in this class, have the luxury of being informed by Bertram Karon’s work, and also the luxury of not being in the current psychiatric political arena where he is routinely discarded. The tragedy is that he is not given credence unless he is directly heard. Also, the type of treatment that he can and does do is an art Unfortunately most can not work with his insight and gentleness. And the vast majority of the schizophrenic population languishes on in a drugged stupor.
REHABILITATION
Medical Care
Medication
Whereas drugs are not usually thought of as rehabilitation, antipsychotic medication is the mainstay of maintenance treatment for schizophrenia. It is through the use of these medications that symptoms such as hallucinations, delusions, thought disorder and bizarre-appearing behaviour will be controlled. Once these symptoms are controlled, a major source of preoccupation for the patients is removed. This in turn allows patients to focus attention on other aspects of their life. Without medication, between 75% - 80% of patients will have acute symptoms of schizophrenia recur within two years. Despite the paramount importance of medication, it is far from the only form of continuing treatment required for somebody suffering from schizophrenia. Many aspects of living in society must be considered when developing programs to help patients overcome deficits in their functioning and acquire new skills.
Medical Follow-up
Medical follow-up is part of rehabilitation. The need for follow-up is two-fold. First, to ensure that the patient has sufficient medication(s) to keep his major symptoms under control and, second, to ensure that the patient's medications are raised or lowered depending on his progress. The intention is to maintain a person on the lowest therapeutic dose of medication possible. Almost invariably, the dose of medication on discharge from hospital is higher than will be required later. However, the lowest dose possible can only be achieved over time with small reductions every 3 - 6 months, depending on the individual. Should major symptoms return while the patient's medication is being reduced, this will be noticed and corrected if he is attending his doctor regularly. A slightly higher dose of medication will ensure that the symptoms are once again controlled, thus avoiding the need for further hospitalization. This, of course, involves the co-operation of the patient and physician primarily but it is hoped that the patient's family and friends can also be involved.
Hospitalization
Hospitalization, mainly in the form of crisis intervention, is an integral part of a rehabilitation program. Patients and families (and therapists) must have ready access to emergency wards, crisis units, day units, and occasionally, to longer stay beds. Knowing they are available lessens anxiety and may make their use less imperative.
Psychotherapy
Supportive psychotherapy is a cornerstone of the rehabilitation program. The individual meets with his therapist to discuss any concerns he may have about any aspect of his life. Medications are frequently a concern and much time will need to be given to the discussion about why they are used, how they work, their side-effects, and how to cope with side-effects. Other issues for which patients frequently seek advice include: housing, vocational issues, leisure time, and quality of life. Obtaining social services, including money, transport, allowances, etc., is also a frequent cause of concern. Supportive psychotherapy gives the patient an opportunity to review his options in any situation. The therapist may be called upon to assist in making a decision. On occasions it may be necessary for the therapist to recommend one approach over others. In other words the therapist may be more direct and act in a more advisory capacity than if he were counselling less ill patients. Self-questioning to do with "why me?" may also arise along with other existential questions which require airing and discussion.
Psychotherapy Treatment Methods
Psychotherapy may occur on an individual basis, where the patient and therapist or therapists meet together to discuss a specific problem and attempt to solve it. Psychotherapy also takes place in group settings. There are primarily two types of group settings. Groups can be intended for discussion and focussed problem solving, or they may be designed to be more open and less intensive. Social groups are an example of the latter. Who should be involved in which approach is determined by the patient and his ability to participate, as well as by the availability of such services.
Alcohol and Street Drugs
Intervention programs for alcohol and drug abuse are part of rehabilitation. Excessive and continuous substance abuse may increase the intensity of psychotic symptoms hallucinations, delusions, thought disorder) and cause the patient additional problems.
The problem of substance abuse is a common one in schizophrenia and must be confronted by exploration, education, supervision, monitoring and peer discussion. Behavioural techniques and supportive psychotherapy will be effective as will family involvement and, sometimes, referral to special drug and alcohol programs.
Entitlements
In the best of all possible worlds, every person is entitled to continuous, comprehensive and co-ordinated care as well as consistent financial resources to meet basic needs such as shelter, food, clothing and spending money. Personal care needs such as hygiene, personal safety, medical care, and mobility need to be looked after. Psycho-social needs, not often thought of as entitlements include: interpersonal relationships, emotional support, meaningful daily recreational and vocational activities, respectful treatment, consideration, unrushed psychotherapeutic help and community hospitality. Such needs must be met before a person can develop a sense of well-being. It is the responsibility of the treatment team/therapists to educate the person suffering from schizophrenia about these entitlements and to assist in obtaining them as fully as possible.
It is important that families and significant others know about the basic requirements needed to achieve a better quality of life.
Finances
It is very important to be sensitive to the financial needs of the individual. If basic living activities such as shelter, food, clothing, transport, social and recreational activities are overlooked, unnecessary unwanted outcomes may result, e.g., sleeping on the street, begging, relapses, imprisonments, medical problems, etc.
Money is usually available from a variety of sources: wages or salary from full-time or casual work, disability payments, welfare, workman's compensation, unemployment insurance, money from relatives/friends, including inheritances and trust funds.
To discover who is eligible for what benefits is best done by consulting with your local social worker. There are assistance plans run by various levels of government: Municipal or Local, Provincial (or State), Federal. Additional subsidies may also be available for rent, transport, food and clothing. Emergency funds are also usually available for genuine emergencies.
Whatever the situation, every attempt should be made to assist the individual to obtain the maximum amount of financial benefits. Even with maximum benefits, many patients live below the poverty line, spending all their income on accommodation and food with little or nothing left for transport and pocket money.
Many families find it humiliating to ask for government support. It is important to keep in mind that the patient frequently finds it less humiliating to accept government money than to take money from parents.
Budgeting
Some people experience great difficulty in managing their money, for others this is not an issue - they budget very well. For those who experience difficulty, money may become a major concern - there is a tendency to spend all the money at once, leaving essential bills unpaid. This may lead to borrowing from relatives, friends or begging, and at times, even to petty theft.
These problems can most practically be overcome by education about budgeting and helping the person learn how to manage his money responsibly. This requires patience, plus direction in banking, assistance with shopping and budgeting patterns, visits to the local grocery store, talks from nutritionists, budget lists or guidelines, etc. For example, milk can be suggested instead of soft drinks, and so on. The individual is familiarized periodically with low-cost food, clothing and basic essentials that are "on special". Since many patients eat in restaurants, they need to be advised about low-cost places that offer a balanced diet. For crises, many communities have emergency food centres and food vouchers.
The individual needs to be assisted in keeping a sense of perspective in deciding how to spend weekly allowances, pay expenses, maintain a small savings account. Some individuals with severe spending difficulty need to be discouraged from the use of cheques, credit cards and frequent crediting at the local corner store.
If money mismanagement persists, some government offices such as the Public Trustee may be involved on a voluntary basis by the patient, or on an involuntary basis if the patient is judged financially incompetent. However, such a move may cost the patient a fee.
It is crucial to assist the individual with schizophrenia to assess changing financial needs and potential resources for managing finances. Rewards and incentives work well. (For instance, vouchers, tickets to a play, movie or sports event.) Adequate financial help and budgeting promote independence.
Housing
Where should the individual suffering from schizophrenia live? In the family home, foster home, boarding home, nursing home, apartment, rooming house or residential setting? The right answer depends on the individual's needs and available housing. The individual's requirements must first be assessed before housing options can be explored.
When selecting a setting, consider the following issues: what kind of setting is required? How much supervision is required? Can the person care for himself? The presenting deficits will determine how much support will be required. Daily supervision may be required for some patients.
Not every patient will need extensive support. He may only need supervision for taking medication or help in the constructive use of leisure time or the development of useful social activities. In such cases, housing which provides once a week supervision may be sufficient.
What happens if the patient is noisy, violent, refusing treatment, smoking up or stealing in the house? Such problems need to be dealt with on an individual basis depending upon the situation, the reasons for the behaviour and the stage of illness. The responsible party must not be rejected or abandoned. A crisis requires helpful intervention. At the same time, it is important to make clear the expectations of the household and the consequences of not meeting them. If skills required for daily living are lacking, they can be learned. If the law is being broken, the police may have to be involved.
Nutrition
What is the best diet for people with schizophrenia? Some individuals with schizophrenia adopt a monotonous diet, eating the same food daily, gaining very little pleasure from taste, or attractive preparation of a meal, snacking on potato chips, chocolate bars and candies. Even worse, they don't eat enough. This may occur when they are actively psychotic, fearing their food is poisoned.
Limited and poor nutritional intake is of concern to clinicians and relatives. We all need good food and a balanced diet. This keeps our weight under control and will likely benefit other medical conditions such as blood pressure, diabetes, dental problems, and constipation, among others.
To ensure that isolated patients have access to food, daycare/aftercare programs often provide nourishing snacks to groups, e.g., green vegetables, cheese, milk, juice, water, fruits, sandwiches etc. At the same time, it is wisest to serve no stimulants such as coffee, tea, cocoa, or soft drinks. Learning shopping and cooking skills is also encouraged. In cases of emergency, most communities have some sort of food bank where patients can be referred for free groceries.
Avocational
Living Skills
Living skills are the activities of everyday life: how to say hello, how to shop, cook, take a bus and the like. People with schizophrenia may have to learn or relearn how to do many of these so they can return to competent functioning. In recent years, a number of centres have been developing programs to teach living skills.
First, a decision must be made about what new skills are needed, then an individualized program for that person needs to be developed. For example, Bing is a 30 year old man who has just been discharged from hospital for the 5th time in one year. He is unsure of himself, worried about his new rooming house, and lacks the initiative to start a conversation. He also has very limited money, clothing and few relatives or friends in the city. However, he has some contact with the local clergy.
A Plan to Help
Help for Bing could include: a visit with him to get acquainted with his new residence, a meeting with his new landlord, an offer of support and assistance during crisis. Bing needs to learn social skills; grooming, hygiene, cleaning and decorating his room, obeying house rules, doing laundry, ironing etc. A worthwhile endeavour might be a walk through the neighbourhood, noting the local variety store and introducing Bing to the owners, a walk to the park, taking notice of low cost clothing and food stores. It is important to also note social agencies, workshops, welfare office, emergency shelter, distress phone number, drop-in or recreation centre or local YMCA or gym facility. This can be followed by weekly home visits to see how comfortable Bing feels with his surroundings and how self-assured he becomes in managing social skills. It is important to be available for crisis management and consultation with landlords and other community workers and the clergy.
For any skill Bing is uncertain about, a step-by-step routine can be developed and then demonstrated. Then Bing can do it himself with and without supervision until he is comfortable and knows how to do it well.
Transportation
Transportation is very important as most patients have to travel distances too great to walk. Can individuals afford to get to treatment? It is crucial to keep this in mind and assist the person as much as possible with necessary benefits, e.g. bus tickets, passes, vouchers.
Can the person use the transit system? Often patients may be afraid to mention their fear of the subway escalators or crowds. This may make the difference between attending a program, job or recreation, or dropping out.
Use of Leisure
Most people who have been ill with schizophrenia are not well off financially and find it hard to know what to do with all the time on their hands. This is perhaps the most important area for constructive rehabilitation - how to help the person who is neither working nor at school to use his time creatively and rewardingly.
It is very useful for rehabilitation programs to be aware of local activities which are not expensive. This will include activities at community centres, athletic centres, libraries, churches, mosques and synagogues, art galleries, museums, parks and recreation centres, universities and colleges and adult education centres as well as community services especially designed for the disabled. Shopping malls, large hotels, art exhibits, skating rinks, swimming pools, pool halls, public gardens, and gardening centres constitute arenas of activities that can be participated in or observed with enjoyment. Crowds may not be welcomed by the patient so the timing of outings may need to be adjusted to coincide with times of lesser traffic. Bridge clubs, stamp clubs, chess clubs are usually of interest, as may be bingo halls, science exhibits, bands, concerts, animal shows and zoos. Big cities may have special drop in centres and other activities for ex-psychiatric patients.
Although socializing is difficult, many ex-patients would like to have opportunities to make friends, especially with members of the opposite sex. Church dances or park concerts may serve that purpose. Specialized social functions for ex-psychiatric patients exist in some communities as do various social-recreational day programs with a focus on group interaction and activity.
For very shy individuals, visiting nurses, members of the family or church organizations, volunteers or others may be available to come to the home and accompany clients to outside functions.
Many people with schizophrenia spend long hours watching television. Although this may be an invaluable distraction, as may be reading or listening to music, these activities have two disadvantages. They are sedentary and solitary. Schizophrenics opt for aloneness frequently and need to be able to retire to privacy when they wish to but some parts of their day need to be among others and active. Exercise and athletic activities need to be promoted.
Shopping, cooking, cleaning, mending may be solitary activities but they are purposeful and leave the doer with a sense of accomplishment. As such, they also need to be promoted.
Talking on the phone with friends is important for continuing contacts which may be difficult to keep up in person.
The provision of telephone services and postal services for the person with schizophrenia is very important.
Spiritual counselling is vital for individuals who have had serious health problems and who continue to lead difficult lives. Meaning is crucial in all lives, perhaps especially so for the psychiatrically ill.
Opportunities for creative outlets - music, art, writing, crafts - are also of great importance. It has been postulated that creativity and schizophrenia are linked in some way. It is certainly true that many schizophrenic individuals are exceptionally creative and feel better if creative urges can be expressed. Keeping a diary is often perceived as meaningful and creative.
Travel often costs too much but when it can be afforded, it offers a change of pace and scenery and a break from routine that is long remembered. Trips need to be carefully planned and organized but form an important part of a comprehensive rehabilitation program.
Some schizophrenics are parents and need to occupy not only themselves but also their children. This is a big responsibility for which they may be ill-prepared and insufficiently supported. Rehabilitation programs need to offer opportunities for parental guidance and skill training as well as to provide baby-sitting arrangements to relieve parents. The health, education and social needs of the children must be attended to as well as the marital and family counselling needs of the parent
Fitness and Exercise
Physical fitness is important to help maintain a sense of well-being. It also helps the individual to function more efficiently. Another important point is that fitness and exercise offer a different focus for people with uncomfortable feelings due to fear, tension and anxiety. There are many ways to achieve fitness.
Types of exercise include: brisk walking, running, stair climbing, dancing, hiking, cycling, swimming, sports volleyball, hockey, baseball, etc.
Potential sites are: local gyms, YMCA, health spas, recreational facilities, day centres, residential settings. The environment should be comfortable and supporting.
Timing: The establishment of a routine is important - morning, lunch, afternoon. It is well to start with small workouts and to increase the duration gradually.
Individuals with schizophrenia should be encouraged to get plenty of moderate exercise daily. A medical check-up is advisable before starting any program. To promote fitness and exercise habits, rewards and incentives, (e.g. tickets to the ball game, movies, exercise outfits, vouchers to fitness clubs) work well.
Vocational Rehabilitation
Employment
Rehabilitation has always been understood to include assistance in job training and job finding. The majority of those with schizophrenia will not, however, do well with traditional vocational rehabilitation. The same difficulties that interfere with keeping jobs (problems in keeping regular hours, slowness, anxieties in dealing with other people, misinterpretation of the motives of others, dissatisfaction with the relative lack of challenge offered by the job or its relatively low pay, feelings of being taken advantage of, inability to make friends on the job, inappropriate dress or behaviour, irrational fears of job related circumstances, inability to cope with authority, with demands, deadlines and evaluations) may also interfere with regular vocational rehabilitation programs which may present the very same obstacles. Special programs which recognize the schizophrenic client's special vulnerabilities are helpful. Flexibility of hours, provision of privacy, anticipation of problems, establishment of an anxiety-free routine all help. Job goals should probably be minimal if the above problems predominate, with a focus, instead, on meaningful activities outside of employment.
For instance, the highly intelligent, sensitive schizophrenic may feel it below his dignity to be training for a job as office help. If the job is seen, however, as part-time, solely for the purpose of making a living and if stress is put on the creative and intellectual potential of evenings and weekends, efforts at job training may be successful.
Many communities have special employment incentives for the ill and disabled and these should be investigated. Psychiatric disability may be invisible (in distinction to individuals who are blind or crippled or hard of hearing) but qualify for special opportunities for the disabled nonetheless.
Each geographic area has its own opportunities. Big cities have more special programs but rural communities may offer more of the kind of work that people with schizophrenia enjoy: slower paced, less crowded, involving nature or animals or children.
Helping others is frequently an activity to which individuals with schizophrenia aspire. The skills and grades required to enter medicine or social work may be impossible but volunteer work is frequently available.
This kind of work does not pay financially but provides the recovering schizophrenic with a sense of purpose and meaning.
Volunteering is an art in itself and it requires skillful and knowledgeable leadership to link potential volunteers with appropriate posts.
A point to keep in mind for families is the importance of valuing whatever the recovering patient spends his time at. The work may be monotonous, ill-paid, repetitious, unchallenging but it provides for the worker a social and occupational niche, an eventually familiar and safe environment, a structured routine, and a diversion from sometimes unpleasant preoccupations. If there is a pay cheque associated with it, so much the better. If there is a sense of meaning or worth to the work, better still.
Retraining
After an illness like schizophrenia, many individuals want to go back to school, either to finish something they had started or to train for something new. Often academic studies are abandoned in favour of something that can be done "with the hands." This is because manual occupations usually involve less interpersonal interaction. Training for work that can be done in relative isolation or during hours when few others are around is often a good idea. Seasonal work is also attractive as it allows for periods of hibernation.
Some individuals with schizophrenia go back to school simply because they enjoy studying, not with a view to graduating. They are intellectually curious and enjoy taking courses and are happy to do so indefinitely. For some, exams and classroom competition may be difficult so it is wise to select courses that do not necessitate exposure to such stresses.
Courses where a certain amount of eccentricity is the norm (art, music, chess, poetry) in class may be the most comfortable ones for people with schizophrenia to attend because they may feel more anonymous and safe. Some prefer correspondence courses which entail the least interpersonal contact.
Education
Education About Illness
Patients need to learn about their illness and how to cope with it. For example, they need to know about the illness, its treatment, side-effects, and what community programs are available to assist them in their recovery from the illness. Depending on the size of the community involved, there may exist organized and systematic rehabilitation programs. Even in small communities, however, through taking special initiatives, therapists and families have been able to develop informal programs that have been extremely useful to their relatives. Once a need has been outlined, some form of program or activity can be developed to answer that specific need. It is important that all concerned in the care of the patient be informed as to what is available by way of formal programming. Social workers and occupational therapists are usually the people to talk to about such issues. There may also be community agencies that are specifically set up to provide information about what is available. This is particularly true in larger cities where the number of programs may be so varied that it is impossible for any one individual to keep pace with them all. In smaller communities, programs may need to be developed and this will mean that all members of the community may have to pull together to solve the problem. For example, local business people, church groups, or other charitable organizations may be quite willing to provide some aspects of what might be required for an individual to expand his functioning. The important point here is that lack of specific formal programs should not be viewed as an insurmountable obstacle in the management of the person suffering from schizophrenia.
Family Support and Education
With any longterm illness the patient must rely heavily on the support of his family, friends, and community in general to assist him in continuing as normal a life as possible. With schizophrenia the situation is no different. Families are thrust into the role of being primary caregivers, whether they realize it or not. Initially, when the illness begins, virtually no family is equipped to cope with it. Over time, with education about the illness and support in matters of management and coping, the hope is that the family or primary care-givers will themselves learn how to care for their ill relative. Most cannot do this alone, hence it becomes vitally important that they have the same access to community facilities that physicians and other therapists expect. Unfortunately, such open access to community resources is rarely available to families.
Families need to know whom they can call upon should they need help. Initially this will mean being aware of who the patient's doctor is, what nurses, occupational therapists, social workers, psychologists etc. are involved in their relative's care. They need to know what community agencies their relative is expected to attend, and whether or not there are any volunteers who might be available to assist them in the care and management of their relative, particularly if he or she is severely disabled. Volunteers can come from all walks of life including people totally unknown to and unrelated to the patient's family, neighbours, landlords, and so on. Frequently families may experience a sense of guilt or loss of status because of the fact that their family member is suffering from schizophrenia. This often makes families reluctant to talk about illness in their relative. However, it is frequently the case that when the family decides to discuss the problem more openly they are quickly approached by others in the community who confess to having the same affliction in their own family.
Such peer support for families is extremely valuable but its usefulness has been overlooked in the past. This is changing and many organizations have been set up to help the relatives contact each other.
The Law
The person with schizophrenia, as well as family members, during the rehabilitation period may find themselves for the first time in their lives involved with the law. This may occur for a variety of reasons.
Minor Offenses
Schizophrenia may lead to disinhibition or social inappropriateness and may involve the individual in public disturbances, in behaviour perceived as offensive, violent or harassing, or in conduct perceived as sexually provocative. Acts of threatened suicide or responses to delusional or hallucinatory stimuli may lead to arrest and legal consequence. It may also happen that the schizophrenic is a victim of violence, theft or sexual assault. He or she may require legal representation to deal with landlords, neighbours or shopowners who accuse him of disturbance. Easy access to legal aid is an indispensable part of an adequate rehabilitation service.
Hospital and Treatment Issues
Legal representation (for patient and family) must also be available to deal with issues of involuntary hospitalization, matters of financial competence during times of acute recurrence of symptoms, guardianship, consent to treatment, access to medical records and, in academic settings, consent in relation to teaching and research. Mental health legislation differs from jurisdiction to jurisdiction and periodically changes. Patients and families, as well as treatment providers, need to be thoroughly familiar with procedures that are required under the law.
For instance, the issue that gives most trouble to most families, is how to arrange treatment for a relative who "is getting sick again" but who does not realize it and who steadfastly refuses a psychiatric assessment. Under the law of most jurisdictions no one (family, doctors, police included) can legally impose assessment unless the person in question is perceived as dangerous, either to himself or to others. Potential dangerousness (by word or action) needs to be carefully documented before the person can be brought to a hospital emergency room for psychiatric assessment against his will. This is a difficult problem for many families and needs to be understood and anticipated, with clear plans made on how family members and treatment providers can best diffuse these situations before they arise.
For example, in situations where violence has been a particular problem, some families have found it helpful to know the local police, their intention being to ensure that the police understand the situation and know what the most helpful actions are in advance of any crisis.
Forensic Psychiatry
Psychiatric patients who commit criminal offenses may be given prison terms or may be admitted to forensic psychiatry treatment units. A different set of laws are operative in that case and, again, legal consultation may be necessary. It is important for the prosecuting attorney and the judge to understand the nature of the offender's illness.
Trust Funds and Wills
Families are frequently concerned about the convalescing schizophrenic's ability to budget appropriately. They may need legal advice on how to help safeguard their relative's financial status. In particular, they worry about what will happen to their schizophrenic son or daughter once they are gone. Legal and financial assistance will be required to draw up appropriate wills and trust funds in order to ensure a safe environment and a satisfying life for their disabled relative.
Prognosis
Prognosis for any particular individual affected by schizophrenia is particularly hard to judge as treatment and access to treatment is continually changing as new methods become available and medical recommendations change.
However, retrospective studies have shown that about a third of people make a full recovery, about a third show improvement but not a full recovery, and a third remain ill19.
There is an extremely high suicide rate associated with schizophrenia. A recent study showed that 30% of patients diagnosed with this condition had attempted suicide at least once during their lifetime20. Another study suggested that 10% of persons with schizophrenia die by suicide21
About Me
- yogeeshcb
- I finished my B.Sc nursing in 2007, and working as an assistant lecturer in VIDYAKIRANA INSTITUTE OF NURSING SCIENCES, 7, 7th cross venkateswara layout, near BK circle, 8th phase, Bangalore 76
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