Schizophrenia: What It Is/What It Isn’t

Misconceptions about schizophrenia abound in the popular culture and in the public mind. Those misconceptions can be a barrier to the people being treated for the disorder, but advances in diagnosis, medication and other treatment options are enabling mental health professionals to achieve a new level of success in caring for schizophrenics.

What It Is
Robert C. Risinger, MD, Assistant Professor of Psychiatry and Behavioral Medicine in the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin, shared his views about what schizophrenia is and isn’t in a recent interview with HealthLink. “Schizophrenia is a neurobiological illness, a neuropsychiatric illness,” Dr. Risinger said. “It is characterized by perceptual distortions, hallucinations where people may see things that aren’t really present. They may hear voices that aren’t really there. It’s also characterized by cognitive difficulties, like difficulties retaining things in short term memory or making sense of what most people would think are common facts or common thought processes.

“What I’m talking about is difficulty in abstracting things,” Dr. Risinger said. “Simple instructions can be difficult (for a schizophrenic). For example, what you might consider easy, such as ‘go down the hall and turn right, then turn left when you see a stop sign,’ they might get very confused with that. They might turn left when they meant to turn right; they may not even recall the instructions in the proper order. So there are cognitive difficulties and perceptual difficulties in schizophrenia.”

What It Isn't
To better know what schizophrenia is, it can also be helpful to consider what it isn’t. A passage from Schizophrenia: A Handbook for Families, published by Health Canada in cooperation with the Schizophrenia Society of Canada, covers a lot of this ground: “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.

An Array of Causes and Effects
Dr. Risinger noted the wide range of severity in how schizophrenia affects individuals. “People can be extremely functional and have schizophrenia,” he said. “People in rather high positions, positions of authority, can have schizophrenia. On the other hand, when you have the illness, just like any illness, you don’t function as well as if you didn’t have it. If you break a leg, you can’t run, or you can’t run very well. It’s the same thing. When you develop schizophrenia, and sometimes it can happen later in life after people have attained certain positions, sometimes they can have a great difficulty in functioning. But nonetheless, they have fairly functional places in society.” Schizophrenics who are unable to take care of “routine” daily living tasks, can’t hold a job, and/or are homeless, represent the more severe end of the spectrum of schizophrenia.

There are many theories about the causes of schizophrenia but none that have yet provided a complete understanding of where the disorder comes from. “If we really, truly knew what causes schizophrenia we’d be miles ahead in terms of treatment,” Dr. Risinger said. “Right now the best we can say from neurobiological studies is that this has something to do with dopamine neurotransmission in certain parts of the brain. The best theories that seem to be borne out with imaging studies, for example, suggest that excess dopamine causes dysfunction in pathways that are involved in both emotion and cognition. There’s too much dopamine, and that causes this disruption of thought processes and also perception.” Dopamine acts as a neurotransmitter in the brain.

Symptoms
Schizophrenia typically strikes rather late in life. For men, Dr. Risinger said, the first diagnosis tends to be around the ages of 18-20 years while for women the first diagnosis tends to be nearer the ages 20-24. There are individuals of both genders who are diagnosed in their mid-teens or as late as their 30s and 40s, Dr. Risinger said. “But, on average, most men tend to be diagnosed a little earlier. The (overall) average is around the age of 20.”

Dr. Risinger described the objective criteria used in diagnosing schizophrenia. “The cardinal symptoms are, number one, the presence of hallucinations; number two, delusions. Again, the cognitive or the thinking process can be so affected that people start to believe things that aren’t really true. They believe that they are somebody else, that they’re being monitored. Paranoia and suspiciousness are often symptoms. There can also be apathy, so there can be emotional effects. In addition to being suspicious and paranoid, people can be depressed. People often do not show very much emotion in their face, even though they’re experiencing it internally.”

“Sometimes there can be apathy in the common use of the term, where people don’t care much about what’s going on around them,” Dr. Risinger said. “(In some cases) people tend not to talk very much. There may be poverty of their thought process; normal people may think about lots of things during the course of the day. Someone with schizophrenia may be preoccupied with just doing the basic details of life. When they’re very sick it may be difficult just to get up in the morning and go through a morning routine – getting dressed, shower or shave, what you normally have to do to get out the door.”

Treatment Options
Medications are the mainstay of treatment options for schizophrenia, according to Dr. Risinger. Two classes of medications – typical and atypical neuroleptics – are used. Essentially, neuroleptics are powerful antipsychotic “tranquilizers” that are believed to work by blocking dopamine nervous receptors. Typical neuroleptics are the “old class” that have side effects including stiffness in the muscles or joints, blurry vision or dry mouth, Dr. Risinger said, while atypical neuroleptics are the “new class” developed within the past decade that have relatively minimal side effects.

Behavioral and social interventions also play a role in treatment of schizophrenia. “Obviously if someone is having difficulty just getting out of bed and getting on with their activities, it helps immensely to have some structure there, somebody there to help them, either a visiting nurse or living in a group situation,” Dr. Risinger said. “Again, people don’t have difficulty conducting their activities of daily life in schizophrenia because they don’t want to. It’s because they have difficulty putting A and B together. They may think ‘OK, now it’s time to brush my teeth,’ but in the meantime they’re not sure where their toothbrush is for a moment and in that time they start to look at the wall and maybe they thought they saw something in the corner of their eye, and now they’re afraid that maybe there is something in the room with them, and maybe they need to be afraid about this, and pretty soon you can see they get way off track.”

Hope for the Future
Genetic research may be critical in the development of future treatments for schizophrenia. “Sometime, certainly within the next 10 years and possibly within the next 5 years, we may have (identified) a number of genes that leave you prone to developing schizophrenia,” Dr. Risinger said. “The best estimates are there’s more than one gene. There are many genes, probably, that are associated with schizophrenia, and it may simply be that some people are prone to it and other people are not. It both runs in families and it does occur in people without any pre-morbid history or family history. And that again is why we believe there’s more than one gene.”

Helping schizophrenics remain “on track” is perhaps the bottom-line goal of treatment, as schizophrenia stays with those who have it for all of their lives. Dr. Risinger stressed that loved ones and friends of schizophrenics can assist in treatment by simply staying in touch with the person, finding ways to get them to take their medication regularly, and getting them to doctor and therapist appointments. Medication and psychosocial intervention together, Dr. Risinger said, offer the best chance for successful outcomes.

This article includes information from the Medical College of Wisconsin Department of Psychiatry and Behavioral Medicine.