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Understanding Schizophrenia: A Q&A With Dr. Faith Dickerson

Q: What is the usual age of onset of schizophrenia?

A: The average age of onset occurs in the mid-twenties, somewhat earlier for men and later for women although individuals may become ill with schizophrenia as early as childhood or later on in adulthood.

Q: Does the onset involve a gradual evolution of symptoms or is it sudden? Could you describe the symptoms of schizophrenia?

A: Schizophrenia is a complex illness with a number of symptoms that may be associated with the disorder. The one associated with schizophrenia is hearing voices, that is hearing voices that are distinct from one's thoughts. These "voices" can be as loud and clear as another person's voice, even though another person is not there. Another typical symptom is delusions. Delusions are false beliefs or misperceptions of the world. For example, a person might see an individual on the street and assume that individual's presence on the street has some particular meaning or poses some particular threat. A delusion is a misperception of or misinterpretation of something in the environment. Another typical symptom of schizophrenia is what we call disorganized behavior, for example a person has difficulty in completing a task in a goal directed way. A person with schizophrenia may also have disorganized speech. This refers to speech that isn't logical - it doesn't make sense. One idea doesn't follow from the other; the speech may be jumbled.

Q: Is paranoia always a feature? It is so often emphasized in media portrayals of schizophrenics.

A: Both delusions and hallucinations can be what we call paranoid - meaning that the person feels that other people are against him/her. But voices and delusions can be of other types. A person can hear voices that are telling them how wonderful they are or a person can hear voices that are telling jokes. Similarly, delusions or false beliefs can be of other types, as well. But the paranoid type is the most common and the type that is most associated with the disorder of schizophrenia. Paranoid schizophrenia is considered a sub-type of schizophrenia. What's really most important is the overarching diagnosis of schizophrenia rather than the sub-type because the sub-types aren't very reliable.

Q: What are the so-called "negative symptoms" of schizophrenia?

A: There is another whole category of symptoms in schizophrenia that are important to describe. These are symptoms that are called "negative" symptoms. And by negative symptoms we do not mean symptoms that are bad, or of negative value. What we are describing by negative is the absence of behavior that usually occurs versus something like hallucinations which are the presence of something that does not occur. By "negative" symptoms, we refer to the absence of motivation, the absence of emotion, or the absence of interest in the world. Very often individuals with schizophrenia, in addition to having symptoms such as hearing voices or being convinced of ideas that are false, also have "negative" symptoms, referring to a withdrawal from the world around them, a reduced interest in things going on, less sociability, less energy, less emotion.

Q: The symptoms of schizophrenia as you have described them sound terribly disabling.

A: Schizophrenia is often debilitating, but not always so. There are a portion of individuals who develop schizophrenia and whose symptoms remit or whose symptoms subside or significantly go away with treatment to the point that the individuals function well and they are productive.

Q: You mentioned early treatment. Can getting treatment soon after onset affect the course of the disease?

A: We think that it does. There are a number of studies that have been done recently suggesting that the earlier that a person receives state of the art treatment, which is an anti-psychotic medication, the more likely they are to be doing relatively well a year or two years down the road. Although we can't say that for sure, we do believe that the earlier that a patient receives medication and psychological treatment, the more likely they are to have a better outcome.

Q: Is early diagnosis and treatment common?

A: Well, interestingly it is not, in spite of the fact that we live in an advanced society with generally good medical care. What studies have found, again somewhat surprisingly, is that oftentimes an individual will go untreated for a year or more with symptoms of schizophrenia. This is probably due to several reasons. One reason is that the symptoms initially may be rather subtle and difficult to detect. Another reason is that the individual may be unaware of having symptoms and may be oblivious to the fact that they are becoming ill. A third reason may be that even when the illness is evident, the individual may be unwilling to accept treatment. Such an unwillingness is often a symptom of the illness. And of course there may be additional problems that delay treatment such as lack of access to care, or insufficient health insurance or health facilities to provide the necessary treatment.

Q: Going back to the statement you made that unwillingness to seek treatment is a feature of the illness; can you elaborate?

A: Sure. The illness schizophrenia is a brain disorder which probably affects parts of the brain that involve an awareness of illness symptoms. Not everyone who has this disorder is unaware of the symptoms. But there is a portion, maybe half of individuals with schizophrenia, who have poor insight about the very evidence of illness symptoms that they are demonstrating. This difficulty may be remedied in part by education about the illness and by ongoing feedback about the illness that may be provided by family members or people providing care. Illness insight is often helped by medication treatment. Unfortunately, in some cases individuals are so oblivious to their need for treatment that they are brought to a hospital under what we call an emergency petition. In such situations, they are mandated to be evaluated for treatment despite their lack of willingness to receive help.

Q: Are you referring to outpatient commitment?

A: Maryland is unusual in not having a provision to provide outpatient treatment to individuals who are unwilling or unable to receive it themselves. We do have a provision in Maryland, as in other states to hospitalize individuals against their will who are presenting some danger and who are unwilling to receive treatment, but the idea of outpatient commitment is a broader one which would ensure ongoing treatment for many individuals who receive treatment in the hospital but then stop it once they leave.

Q: Is there a relationship between schizophrenia and aggressive, violent or criminal behavior?

A: Well the answer is yes and no. No, in that the vast majority of individuals with schizophrenia are not violent. However, when individuals with schizophrenia are untreated with medication and/or they have a co-occurring problem with substance abuse, then their risk of aggressive behavior is greater than the general public. This is unfortunate for everyone involved, and is stigmatizing for those other individuals who have schizophrenia and who are receiving treatment and do not pose that kind of danger or risk.

Q: Let's talk more about the signs and the symptoms and how they are viewed by professionals making the diagnosis. You've got A, B and C, so you've got schizophrenia-is it that clear cut?

A: Usually at the time of onset it is not that distinct. This is because the symptoms of schizophrenia may develop gradually because the symptoms may overlap with those of other psychiatric disorders. Also the diagnosis of schizophrenia is difficult to make in some cases because we do not have any biological test for schizophrenia - nor do we for other psychiatric disorders. The diagnosis of schizophrenia is made on the basis of a person's signs and symptoms over a period of time. The symptoms must be acutely present for at least one month and present to some degree for six months, so it is not an easy diagnosis to make on the basis of a single observation.

Q: In this era of technology, one would think that you could take an MRI, or another type of image, of the brain of a person suspected of having schizophrenia, and if this severe brain disorder was present, you'd be able to see it.

A: That's right and that's a very interesting issue that you bring up. There have been many brain imaging studies of individuals with schizophrenia in an attempt to better understand the etiology of the disorder and what is exactly wrong in the brain. We do know that as a group individuals with schizophrenia have certain differences in their brains from those individuals who do not have schizophrenia, However, because there is a lot of variation among individuals with schizophrenia as well as among individuals who do not have schizophrenia we cannot use the results of those tests to diagnose any one individual.

Q: Alright, so the diagnosis has been made. What comes next? What is the treatment for schizophrenia?

A: Because schizophrenia affects so many different aspects of a person's life, the treatment is necessarily complicated. The most essential aspect of treatment for schizophrenia is anti-psychotic medication which is the centerpiece of treatment. However, because the illness affects a person's behavior, affects their relationships, affects their capacity to work, affects their ability to get along with family members, psychosocial treatment focused on those other areas may also be important.

Q: Does psychosocial treatment include rehabilitation?

A: Yes, rehabilitation can take place in terms of work-related skills, or can take place in terms of interpersonal skills. Individuals with schizophrenia may need assistance in terms of managing their day to day lives so we have residential and case management service for individuals helping them with all day to day needs. Fifty years ago most individuals with schizophrenia spent significant portions of their lives in hospitals and long-term institutional care. That is no longer the case. Almost all individuals with schizophrenia now live in the community as outpatients and there is an attempt, not always enough, but there is an attempt, to provide support and care for them in outpatient settings.

Q: Why do most individuals with schizophrenia now live in the community?

A: Well the deinstitutionalization of individuals with schizophrenia started in the 1950's with the first discovery of a medication, thorazine, which was helpful for individuals with schizophrenia, and then had a very quick momentum, driven in part by humanitarian issues for individuals, by financial considerations, as well as the fact that improved treatments such as anti-psychotic medications were increasingly available. Unfortunately deinstitutionalization was not implemented in a comprehensive or thoughtful, or well planned way so that individuals were often thrust into the community without much preparation or support. Efforts have been made to try and rectify this, although it is an ongoing problem.

Q: What percentage of homeless persons suffer from schizophrenia?

A: Estimates are that at least 30% of people who are homeless have a diagnosis of schizophrenia or other severe mental illness. Individuals with schizophrenia are typically unable to work so they do not have a source of support and that would certainly put them at risk for homelessness. Their behavior may be alienating to other people so they may have lost contact with friends and family. They may not have the resources to be able to find housing or find other accommodations.

Q: How do we reach people who are on the fringes, homeless and mentally ill? Is it necessary to intervene?

A: Well it's difficult because typically those individuals are also among the group that are unaware of the illness symptoms and therefore are less likely to reach out for and accept treatment. So the intervention with these individuals involves very sophisticated outreach efforts to try and engage them in some kind of relationship with care providers so that they are more likely to receive help -- both medication treatment and psychosocial services.

Q: What causes schizophrenia?

A: The cause of schizophrenia is unknown. There is some evidence that schizophrenia or the susceptibility to schizophrenia may be in part inherited. We know this by the fact that schizophrenia runs in families to some extent. However, the majority of individuals who develop schizophrenia do not have any immediate family members who have the illness. So we know that other factors must be involved. The leading hypothesis currently is that schizophrenia represents some kind of neurodevelopmental problem -- that is, there is some deficit in the developing brain that emerges as schizophrenia symptoms in early adulthood. There are theories that perhaps a virus is involved that is present at birth and then leads to some of the symptoms of schizophrenia. But at this point, the etiology, the cause of the disorder, is not understood.

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Last modified: Wednesday, April 16, 2014

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