Although an exact definition of schizophrenia still evades medical researchers, the evidence indicates more and more strongly that schizophrenia is a severe disturbance of the brain’s functioning. In The Broken Brain: The Biological Revolution in Psychiatry, Dr. Nancy Andreasen states “The current evidence concerning the causes of schizophrenia is a mosaic. It is quite clear that multiple factors are involved.
These include changes in the chemistry of the brain, changes in the structure of the brain, and genetic factors. Viral infections and head injuries may also play a role….finally, schizophrenia is probably a group of related diseases, some of which are caused by one factor and some by another.” (p. 222).
There are billions of nerve cells in the brain. Each nerve cell has branches that transmit and receive messages from other nerve cells. The branches release chemicals, called neurotransmitters, which carry the messages from the end of one nerve branch to the cell body of another. In the brain afflicted with schizophrenia, something goes wrong in this communication system.
Many families of people with schizophrenia have found comparing the brain to a telephone switchboard very helpful in understanding the disease. In Schizophrenia: Straight Talk for Family and Friends (p. 41), Maryellen Walsh states “In most people the brain’s switching system works well. Incoming perceptions are sent along appropriate signal paths, the switching process goes off without a hitch, and appropriate feelings, thoughts, and actions go back out again to the world….in the brain afflicted with schizophrenia…perceptions come in but get routed along the wrong path or get jammed or end up at the wrong destination.”
Schizophrenia may develop so gradually that the family and even the person with the disease may not realize that anything is wrong for a long period of time. This slow deterioration is referred to as gradual-onset or insidious schizophrenia. A gradual build-up of symptoms may or may not lead to an acute or crisis episode of schizophrenia. An acute episode is short and intense, and involves hallucinations, delusions, thought disorder, and an altered sense of self.
Sometimes schizophrenia has a rapid or sudden onset. Very dramatic changes in behaviour occur over a few weeks or even a few days. Sudden onset usually leads fairly quickly to an acute episode. Some people have very few such attacks in a lifetime; others have more. Some people lead relatively normal lives between episodes. Others find that they are very listless. depressed, and unable to function well.
In some, the illness may develop into what is known as chronic schizophrenia. This is a severe, long-lasting disability characterized by social withdrawal, lack of motivation, depression, and blunted feelings. In addition, moderate versions of acute symptoms such as delusions and thought disorder may be present in the chronic disorder.
Psychiatrists divide the symptoms of schizophrenia into “positive” and “negative” categories. This can be confusing. Dr. E. Fuller Torrey explains that the adjective “positive” “…denotes those symptoms which are present and should be absent…”; “negative” those “…that are absent but should be present….” (Torrey, Surviving Schizophrenia: A Family Manual, revised edition, p. 79). This classification system is believed to be helpful for research purposes. It may suggest more promising forms of treatment and may help predict the outcome of the illness.
Positive Symptoms
Hallucinations are thought to be a result of over-sharpening of the senses and of the brain’s inability to interpret and respond appropriately to incoming messages. A person with schizophrenia may hear voices or see visions that are not there, or experience unusual sensations on or in his or her body. Auditory hallucinations, the most common form, involve hearing voices that are perceived to be inside or outside of the person’s body. Sometimes the voices are complimentary, reassuring, neutral. Sometimes they are threatening, punitive, frightening, and may command the individual to do things that may be harmful.
Delusions are strange and steadfast beliefs that are held only by the observer and that remain despite obvious evidence to the contrary. For example, red and green traffic signals may be interpreted by someone with schizophrenia as instructions from space aliens. Many people with schizophrenia who suffer from persecution delusions are termed “paranoid.” They believe that they are being watched, spied upon, or plotted against. A common delusion is that one’s thoughts are being broadcast over the radio or television, or that other people are controlling the ill person’s thoughts. Delusions are resistant to reason. It is of no use to argue that the delusion is not “real.”
Thought disorder refers to problems in the way that a person with schizophrenia processes and organizes thoughts. For example, the person may be unable to connect thoughts into logical sequences. “Racing thoughts” come and go so rapidly that it is not possible to “catch them.” Because thinking is disorganized and fragmented, the ill person’s speech is often incoherent and illogical. Thought disorder is frequently accompanied by inappropriate emotional responses: words and mood do not appear in tune with each other. The result may be something like laughing when speaking of sombre or frightening events.
Altered sense of self is a term describing a blurring of the ill person’s feeling of who he or she is. It may be a sensation of being bodiless, or non-existent as a person. The ill individual may not be able to tell where his or her body stops and the rest of the world begins. It may be as if the body is separated from the person.
Negative Symptoms
Lack of motivation or apathy is a lack of energy or interest in life that is often confused with laziness. Because the ill person has very little energy, he or she may not be able to do much more than sleep and pick at meals. Life for the person with schizophrenia can be experienced as devoid of interest.
Blunted feelings or blunted affect refers to a flattening of the emotions. Because facial expressions and hand gestures may be limited or nonexistent, the ill individual seems unable to feel or show any emotion at all. This does not mean that the individual does not feel emotions and is not receptive to kindness and consideration. He or she may be feeling very emotional but cannot express it outwardly. Blunted affect may become a stronger symptom as the disease progresses.
Depression involves feelings of helplessness and hopelessness, and may stem in part from realizing that schizophrenia has changed one’s life, from realizing that the “special feeling” experienced in the psychotic state is an illusion and that the future looks bleak. Often the person believes that he or she has behaved badly, has destroyed relationships, and is unlovable. Depressed feelings are very painful and may lead to talk of, or attempts at, suicide. Biological changes in the brain may also contribute to depression.
Social withdrawal may occur as a result of depression, as a result of a feeling of relative safety in being alone, or as a result of being so caught up in one’s own feelings and fearing that one cannot manage the company of others. People with schizophrenia frequently lack the resources needed to show interest in socializing.
It is most common for schizophrenia to attack young people for the first time between 15 and 30 years of age, but the illness may develop as late as age 40. It occurs in all races, in all cultures, in all social classes, and in both sexes. The risk for anyone in the population becoming schizophrenic is generally accepted as one percent. This means that about 250,000 Canadians will suffer from this illness at some point in their lives.
Schizophrenia is not now curable, but through the use of anti-psychotic medication and psychotherapy, the positive symptoms of schizophrenia can usually be controlled. Full recovery may occur, but it cannot be predicted. In some cases people get better on their own. Remission usually comes within the first two years and is rare after having the disease for five years. With advancing age, particularly after 40, life for the person with schizophrenia often becomes less difficult: positive symptoms tend to diminish and medication can often be taken at a low dose or less frequently.
An Illness Not Understood: The Stigma Of Schizophrenia
The stigma of schizophrenia is a barrier to those trying to rehabilitate themselves. It is also a very real problem for their families. Therefore, those involved with schizophrenia are concerned about the dozens of misconceptions about the illness. Schizophrenia is a disease that is not well understood and is greatly feared. Most of what people think they know about schizophrenia is wrong. People confuse schizophrenia with split personality or multiple personality. They believe that people with schizophrenia are violent and dangerous. A limited number are, of course, but media publicity about particularly frightening and bizarre crimes of violence committed by people with mental disorders has left the public with the impression that most persons with schizophrenia are violent. This is not true. The majority are not.
However, wide differences in the effect that schizophrenia has on different people and the difficulty in understanding the actions of someone in a deeply psychotic state, whose thinking is thoroughly confused, reinforce the public’s concern. Some believe that people with schizophrenia have weak personalities and have “chosen” their madness. Many believe that schizophrenia is the result of bad parenting and childhood trauma.
One parent stated that he was often accused of abandoning his daughter when he took her to the hospital. Another parent said that clerks in stores ignored her son when he asked for help or tried to make a purchase. Some religious groups hold the view that the illness is one of God’s punishments.
The families consulted believe that it is important to understand how the stigma surrounding schizophrenia developed. The term “schizophrenia” was introduced in 1911 by a Swiss psychiatrist, Eugen Bleuler. The word comes from the Greek schizo meaning “split” and phrenia meaning “mind.” Bleuler wanted to convey the split between what is perceived, what is believed, and what is objectively real. He did not mean that the person with schizophrenia is split into two personalities, but that there is a splitting away of the personality from reality. The concept of “split,” however, has led to schizophrenia being confused with multiple personality, a less common and very different psychiatric disorder, much publicized through such stories as Dr. Jekyll and Mr. Hyde, The Three Faces of Eve, and Sybil. Today, many health care professionals regret the existence of the term “schizophrenia” because of the confusion and misunderstanding that surround it.
Added to this basic confusion is a history of blame. Families agree that blame is a major stumbling block to seeking and receiving support.
In the late 1800s and the early part of this century, three competing views about the nature of mental illness gained acceptance in the psychiatric profession.
Biological psychiatry grew from the research of Dr. Emil Kraepelin in Germany; psychoanalysis from the findings of Dr. Sigmund Freud and his colleagues in their studies on neuroses in Austria; and behaviourism from the work of Dr. John B. Watson in the United States. Kraepelin’s views predominated the thinking of psychiatrists in Europe, while both psychoanalysis and behaviourism (see Glossary) flourished in North America (Andreasen, The Broken Brain, pp. 11-20).
In the 1950s, many North American psychiatrists began to believe that schizophrenia resulted from a form of psychic trauma inflicted on the individual early in life, typically by parents. Mothers of those with schizophrenia were believed to be over-anxious, obsessive, and domineering. These women were labelled “schizophrenogenic.”
One mother said she almost understood this. “When you are pushing to get help for your child, it is easy for some to ‘put the cart before the horse’ and point to this pushiness and tension as the cause of your child’s problem, rather than the result of it.” Gradually, blame was placed on the family as a unit. Theorists noticed poor family functioning where there was someone with schizophrenia, and confused the effect of the illness with its cause.
Two other theories contributed to the mythology surrounding schizophrenia. The American psychoanalyst Thomas Szasz pronounced that schizophrenia, like all other mental illnesses, is a set of behaviours, not a disease. The late R.D. Laing, a British psychiatrist, suggested that it is really a “healthy” response to an insane world. People burdened with terrible stress act “crazy” in an effort to adapt.
Scientific research and factual data have discredited these theories. Unfortunately, they were all popular enough at one time to have gained public attention. You may still run into health care professionals who will suggest that you “caused” your relative’s illness, and that a continuing family relationship may hinder recovery.
Aside from the history of blame, the symptoms of the illness itself can often add to the stigma of schizophrenia. The odd and unpredictable behaviour, poor functioning, or lack of good health habits can be disturbing to others. News coverage on acts of violence or suicides committed by people reported as having schizophrenia serve to add to the stigma, even if unintentionally.
Families often find the stigma difficult to handle. Some try to hide the illness in the family. Others, however, prefer to speak openly about it. They say this gives peace of mind and allows them to join with others to try to remove the stigma.
Recognizing That Something Isn’t Right
Family members commonly reported that they knew at an early stage that something wasn’t right with their relative. They sensed that their son or daughter, brother or sister, husband or wife was not merely going through a phase, was not in a temporary bad mood, was not reacting to the overuse of drugs or alcohol. Some, however, said they were taken completely by surprise. They assumed that whatever unusual behaviour they had observed was due either to normal adjustment or to some degree of delinquency. All urge that people reading this Handbook trust their instincts and seek help immediately if they become concerned. Remember that you know your relative best.
Early Warning Signs - a list compiled from the focus group discussions
• inability to sleep, unusual waking hours, day and night mixed up
• social withdrawal, isolation, indifference
• deterioration in social relationships
• hyperactivity, or inactivity, or periods of alternation between the two
• inability to concentrate, noticeable difficulty in making decisions
• unusual preoccupation with religion or the occult
• hostility, suspicion, fearfulness
• over-reaction to peer or family disapproval
• deterioration in personal hygiene
• frequent hitch-hiking trips for unclear reasons
• excessive writing or childlike printing without clear meaning
• unusual emotional reactions
• flat, expressionless gaze
• staring, not blinking, or blinking incessantly
• unusual sensitivity to stimuli (noise, light)
• smelling and tasting things differently
• peculiar use of words or language structure
• bizarre behaviour: refusal to touch people, constant wearing of gloves, shaving head or body hair, cutting oneself, threats of self-mutilation
None of these signs by themselves indicate the presence of mental illness. Few of those who helped compile this list said that they had acted on these early warning signs. With the knowledge of hindsight, these family members urge you to seek medical advice if several of the behaviours listed above are present, or constitute a marked change from previous behaviour and persist over a few weeks.
Many families noticed that there was no logical flow of ideas during conversation. Others noticed that their relative began speaking out loud to no one, and did not seem to hear other people speaking to him or her. One young man began researching all religions and cults.
Another young man began turning off all radios because he believed that he was receiving messages through this medium. In some families, their relative destroyed his or her bank book, birth certificate, and photographs. Signs of paranoia became apparent in many cases. A relative would begin talking about plots against him or her and had “evidence” that he or she was being poisoned. One man said that his wife assumed that whenever she saw people talking, they were talking about her.
Eventually, families reached a point where they could not tolerate the differences in behaviour any longer. Many commented that there was much confusion in the home, with some resentment and anger toward the person behaving strangely. Siblings often felt that their brother or sister was merely lazy and shirking responsibilities; children were embarrassed and confused by their parent acting so differently; parents disagreed on how to handle their child’s problems; the stability of the marriage frequently suffered. All contributors stressed that you should not wait for tensions to reach such extreme levels. You should seek outside help from your family physician or some other appropriate source.
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Arthur Buchanan
Out of Darkness & Into the Light
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