Internet Mental Health

SCHIZOPHRENIA




Diagnostic Features of Schizophrenia

SYMPTOM DEFINITION SELF-DESCRIPTION
PSYCHOSIS
Impaired Reasoning Difficulty analyzing and finding solutions to problems in day-to-day life; poor judgment "My judgment or ability to solve problems isn't good."
Perceptual Dysregulation Having odd or unusual perceptions e.g. feeling unreal, things looking unreal, out-of-body feeling "Things around me often feel unreal, or more real than usual."
Unusual Beliefs or Experiences Firmly believing a false belief (delusion) or false perception (hallucination) e.g. hearing “voices” "I've had some really weird experiences that are very difficult to explain."
Disorganized Speech or Behavior Speech is frequently derailed or incoherent; OR grossly disorganized or catatonic behavior "My thoughts or behaviors often don’t make sense to others."
DETACHMENT
Loss of Interest or Pleasure Lacking interest or pleasure in doing one’s usual activities "I rarely get enthusiastic about anything."
Sockal Withdrawal Avoiding social contacts and activities "I have little interest in social activities."
Intimacy Avoidance Avoidance of close, romantic, or sexually intimate relationships "I steer clear of romantic relationships."
Restricted Emotions Being emotionally distant and unresponsive "I never show emotions to others."

Onset:

In the developed world, the median lifetime prevalence of Schizophrenia is 0.5% (i.e., 1.5 million Americans). Schizophrenia is a chronic medical condition with periods of remission and relapses over a patient's lifetime. The onset of Schizophrenia usually occurs in adolescence or early adulthood. It starts (slowly or quickly) with a prodomal phase of increased social withdrawal, apathy, and academic impairment. This is followed by (1) psychosis (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior), often (2) cognitive impairment (forgetfulness, impaired reasoning), and (3) "negative symptoms" (social withdrawal, intimacy avoidance, restricted emotion, and loss of interest or pleasure). There is often suspiciousness, distractibility, and emotional distress (depressed mood, self-harm). The first 6 months of this disturbance is (by definition) diagnosed as being Schizophreniform Disorder. If Schizophreniform Disorder persists longer than 6 months, the condition is (by definition) rediagnosed as being Schizophrenia. (On 2-4 year follow-up, between 80.9% to 83% of individuals initially diagnosed as having Schizophreniform Disorder are rediagnosed as having Schizophrenia.)

Treatment:

  • "Positive Symptoms":
    (i.e., psychotic symptoms) are episodic or continuous and can be controlled with antipsychotic medication.

  • "Negative Symptoms":
    (e.g., lack of interest or motivation, lack of emotional expression, lack of social communication, social withdrawal) are much more difficult to treat. However, combination therapy with antipsychotic plus antidepressant medication is sometimes helpful.

  • Denial of illness:
    is very common. Initially, most individuals with schizophrenia believe that they are not ill. Usually, this realization only comes after repeated psychiatric hospitalizations.

  • Cognitive Impairment:
    (e.g., forgetfulness, impaired reasoning) is the least responsive to current treatment.

  • Long-Acting (or "Depot") Antipsychotic Medication:
    There are now long-acting antipsychotic medications which effectively treat psychosis and prevent relapse. When long-acting antipsychotic medication is given by injection every 1-3 months, the relapse rate and overall level of functioning is dramatically better than that of oral antipsychotic medication. Injections once every 2 months of the long-acting antipsychotic medication aripiprazole lauroxil (Brand name: Aristada®, Alkermes®) or every 3 months of the long-acting antipsychotic medication paliperidone palmitate (Brand name: Invega®, Sustenna®) dramatically decrease relapse rates in Schizophrenia. The majority of severely ill, psychotic individuals are not receiving treatment with the much more effective long-acting antipsychotic medications. The result is tragic; now in the U.S. there are more mentally ill persons in jails and prisons than hospitals.

  • Treatment Refusal:
    Untreated Schizophrenia often has periods of remission followed by relapse, and a few people can go for a few years between their psychotic relapses. However, each psychotic relapse permanently decreases the person's level of cognitive, occupational, and social functioning.

Prognosis:

Currently, the majority of individuals with Schizophrenia secretly stop taking their antipsychotic medication, thus remain moderately disabled. Treatment with antipsychotic medication more than doubles the rate of symptomatic remission compared to never-treated patients. The best outcome in Schizophrenia results from early detection of the first psychotic episode and life-long treatment with long-acting antipsychotic medication as well as continued psychosocial treatment and support. When individuals with Schizophrenia stop their antipsychotic medication, the median time to relapse is 274 days .

Unfortunately, 70% to 85% of individuals with Schizophrenia lack full-time competitive employment. In Schizophrenia, at one year follow-up, only 33% of individuals started on oral antipsychotic medications stay on them. This refusal to stay on antipsychotic medication largely accounts for the tragically high rate of unemployment and relapse in Schizophrenia.

Individuals with schizophrenia are less of a violence risk than people with substance abuse or antisocial personality disorder. However, when compared with the general population, individuals with schizophrenia have an increased risk of violent behavior. The more severe the illness, the greater the risk of violence.

Substance abuse (nicotine excluded) has been reported in about half of people with schizophrenia in the USA.

The mortality rate among people with schizophrenia is four times higher than in the general population. Suicide, cancer, and heart disease are the leading causes of death.

There is a very high death rate for people with schizophrenia in India. There the mean age at death for people with schizophrenia is 34.2 years, which is well below India's national average life span of 60.5 years. The survival rate for people with schizophrenia is much better in countries with well-developed mental health systems.

SAPAS Personality Screening Test

Individuals with this disorder would answer "Yes" to the red questions (except #3):

      In general, do you have difficulty making and keeping friends?
      Would you normally describe yourself as a loner?
      In general, do you trust other people? (No)
      Do you normally lose your temper easily?
      Are you normally an impulsive sort of person?
      Are you normally a worrier?
      In general, do you depend on others a lot?
      In general, are you a perfectionist?

Answer "Yes" or "No" to each of these 8 questions.




7-Question Well-Being Screening Test (By P. W. Long MD, 2020

Individuals with this disorder would have a significant impairment in the behaviors that are displayed in red :

      Agreeableness: I was kind and honest.
      Conscientiousness: I was diligent and self-disciplined.
      Openness/Intellect:I showed good problem-solving and curiosity. (Instead had psychosis [must have delusions, hallucinations, or disorganized speech; some may have grossly disorganized or catatonic behavior]; not disoriented for person, place or time).
      Sociality: I was gregarious, enthusiastic, and assertive. (Instead had loss of interest or pleasure, being emotionally distant and unresponsive, avoiding social contacts and activities, avoidance of close, romantic, or sexually intimate relationships)
      Emotional Stability: I was emotionally stable and calm.
      Physical Health: I was physically healthy.
      Role Functioning: I functioned well socially and at school/work.

How often in the past week did you do each of these 7 behaviors:



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Diagnose Schizophrenia

Diagnose Psychotic Disorders

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Schizophrenia 295.90

This diagnosis is based on the following findings:

  • Psychotic symptoms were not due to a general medical condition

  • Psychotic symptoms were not due to substance use or other treatment

  • Not due to Schizoaffective or Mood Disorder

  • Auditory hallucinations (still present)

  • Lack of emotional expression, verbal expression, or motivation (still present)

  • Psychotic symptoms were present for at least one month

  • Psychosis caused clinically significant distress or disability

  • Continuous signs of the disturbance persisted for at least 6 months

  • Not due to Autism Spectrum Disorder or a Communication Disorder of Childhood Onset

TREATMENT GOALS:

  • Goal: prevent auditory hallucinations.
    If this problem persists: She will continue hearing imaginary things that others can't hear (like noises or someone whispering or talking).

  • Goal: prevent "negative symptoms" of Schizophrenia.
    If this problem persists: She will continue to have lack of: emotional expression, verbal expression, or motivation.


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Youth's Greatest Disabler

Schizophrenia is youth's greatest disabler; yet 10%-20% fully recover on medication.

This disorder, at some point, involves a 1-month active-phase during which 2 (or more) of the following are present for a significant portion of time: (1) delusions, (2) hallucinations, (3) disorganized speech [e.g., frequent derailment or incoherence], (4) grossly disorganized or catatonic behavior, (5) negative symptoms [i.e., diminished emotional expression or inability to initiate or persist in goal-directed activities]. At least one of these must be (1), (2), or (3).

For a significant portion of the time since the onset of this disorder, social and/or occupational level of functioning is markedly below the level achieved prior to the onset. Continuous signs of this disorder must have persisted for at least 6 months. This 6 months must include at least 1 month of active-phase symptoms. The remainder of this 6 months may be manifested by only negative symptoms or other active-phase symptoms present in mild form (e.g., odd beliefs, unusual perceptual experiences).

Any manic or major depressive episodes that may have occurred during this disorder were present only for a minority of the total duration of the active and residual periods of this disorder. This disorder is not caused by a medical condition, medication, or drug of abuse.

Cognitive Deficits

Cognitive deficits in schizophrenia are core features of the illness. They are the strongest predictors of social and vocational functioning during schizophrenia.

Individuals with youth-onset schizophrenia have severe cognitive deficits. The mean premorbid IQ is 93.6 in people who develop schizophrenia, compared with a population mean of 100 (SD 15).

Higher IQ may be protective in schizophrenia, perhaps by increasing active cognitive reserve.

Usually following psychosis onset, IQ is stable. It is IQ at psychosis onset rather than premorbid IQ that best predicts illness severity.

In a 3-year followup study of individuals with first-episode schizophrenia or schizoaffective disorder, 25% showed stable low IQ, 31% showed stable IQ in the average/high range, and 44% demonstrated intellectual deterioration by 10 IQ points or more. Schizophrenia causes significant cognitive impairment in 85% of the individuals suffering from this disorder, but early treatment with antipsychotic medication can stop this cognitive impairment, and may improve it.

There is impairment of thought processing speed, attention, working memory, visual learning, verbal learning, reasoning, and social cognition (i.e., emotional intelligence and social awareness). In addition, there often is poverty of speech, and poverty of thought content. However, these cognitive deficits primarily involve impairments of attention, working memory, and executive control.

The psychotic symptoms seen in schizophrenia are often episodic; whereas the cognitive impairments are continuous. The high unemployment rates seen in schizophrenia are usually due to these cognitive impairments.

These cognitive deficits are usually present since childhood. Children who will eventually develop schizophrenia begin school at a level of functioning that is a full grade behind their peers, with the gap increasing by the time they finish high school.

Course

The prevalence of schizophrenia is about 1 per 10,000 in children, and 1-2 per 1000 in adolescents. At some point in their life, 0.48% of Americans will develop Schizophrenia, with most cases starting in young adulthood.

Schizophrenia usually starts between 10 and 25 years for men and between 25 and 35 for women, but 23% of people with schizophrenia experience their first episode after the age of 40. In a small group of people, schizophrenia has its onset after age 60.

Often the earlier the age of onset, the more severe the illness. The onset may be abrupt or insidious.

Usually schizophrenia starts gradually with a prepsychotic phase of increasing negative symptoms (e.g., social withdrawal, deterioration in hygiene and grooming, unusual behavior, outbursts of anger, and loss of interest in school or work). A few months or years later, a psychotic phase develops (with delusions, hallucinations, or grossly bizarre/disorganized speech and behavior).

Individuals who have an onset of schizophrenia later in their 20's or 30's are more often female, have less evidence of structural brain abnormalities or cognitive impairment, and display a better outcome.

Schizophrenia usually persists, continuously or episodically, for a lifetime. Complete remission (i.e., a return to full premorbid functioning) off antipsychotic medication is uncommon. Yet 10%-20% of individuals with schizophrenia fully recover on antipsychotic medication.

Some individuals appear to have a relatively stable course, whereas others show a progressive worsening associated with severe disability. The psychotic symptoms usually respond to treatment with antipsychotic medication, whereas the negative symptoms are less responsive to antipsychotic medication. Often the negative symptoms steadily become more prominent during the course of Schizophrenia.

"Basic Symptoms" of Schizophrenia

There are "basic symptoms" of schizophrenia that are continuously present throughout the illness. These "basic symptoms" are detected only by the person with schizophrenia, and can't be detected by others. These "basic symptoms" are often the first symptoms of schizophrenia to develop.

These "basic symptoms" of schizophrenia are:

  • Thought interference , ie, an intrusion of completely insignificant thoughts hindering concentration/thinking.

    ("I can't help thinking about other things, which is very distracting.")

  • Thought perseveration , ie, an obsessive like repetition of insignificant thoughts or mental images.

    ("I always have to mull over what I just said. I can't stop thinking about what I might have said wrong or what I could have added although I really don't think that anything was wrong with what I said.")

  • Thought pressure , ie, a self-reported "chaos" of unrelated thoughts.

    ("If I am stressed out my mind gets chaotic and I have great problems thinking straight. Too many thoughts come up at once.")

  • Thought blockages either with or without intrusion of a new thought also includes a sudden loss of the thread or train of thoughts.

    ("Sometimes my thoughts just stop, are suddenly gone, like being cut off.")

  • Disturbance of receptive language , ie, paralysis in the immediate comprehension of simple words/sentences, either read or heard, that can result in giving up reading or avoiding conversations.

    ("I often can't get the meaning of common words when I am reading.")

  • Disturbance of expressive speech , ie, problems in producing appropriate words, sometimes also experienced as a reduction in active vocabulary.

    ("Sometimes I think it must appear as if English were really my second language, like I don't know English very well because I have difficulties expressing myself. I forget the words.")

  • Disturbances of abstract thinking , ie, an unusual basic symptom seen when asking the patient to explain sayings or idioms.

    ("Sometimes I get puzzled if a certain object or event only stands as a metaphor for some more general, abstract or philosophical meaning.")

  • Inability to multi-task .

    ("Doing two things at once has become impossible even with the simplest things. I always have to concentrate on one thing at a time, like if I prepare a sandwich, I cannot do anything else, like watch a film.")

  • Captivation of attention by details of the visual field that catches and holds the look.

    ("Sometimes an object really seems to stand out from the rest of what I see. My eyes then fix on it. It's like being spellbound, even though I don't want to look at it at all.")

  • Decreased ability to discriminate between perception and ideas, true memories and fantasies .

    ("I thought about my grandparents. Then a weird thing happened: I couldn't remember if knew my grandparents properly, if they were real or if they were just in my imagination. Did I know them, or had I made them up?")

  • Unstable ideas of reference with insight .

    ("When I was listening to the radio the idea that the lyrics had some special meaning for me suddenly popped up into my head. Of course I knew straight away that it was just my imagination, a kind of weird thing. I did not have to think twice about it to know that.")

  • Derealization , ie, a decreased emotional and gestalt connection with the environment.

    ("Sometimes, I feel disconnected from the world around me, like I'm under a glass cover.")

  • Visual or acoustic perceptual disturbances with insight . Unlike hallucinations or schizotypal perceptual distortions, basic symptom perceptual observations are not regarded as real but are immediately recognized as a sensory or subjective problem. The knowledge that the misperception, eg, a wrong coloring, distorted shape or changed sound quality/intensity, has no counterpart in the real world is immediate and unquestioned.

    ("People suddenly seemed changed and had different hair colors.")

"Negative Symptoms" of Schizophrenia

Unfortunately the majority of individuals with schizophrenia do not fully recover. However much of this disability can be prevented if individuals with schizophrenia stay on their antipsychotic medication. Unfortunately, most don't.

Research has shown that it is not the psychotic symptoms of schizophrenia that cause most of its disability. Instead, the poor functioning in schizophrenia is primarily due to its: (1) emotional and motivational deficits (called the "negative symptoms" or "deficit syndrome"), and (2) cognitive deficits (especially impaired verbal memory, processing speed and attention).

One hundred years ago, the early psychiatrists noticed that many individuals with schizophrenia lost their emotion and motivation. Kraepelin (1919) observed that there was "a weakening of those emotional activities which permanently form the mainsprings of volition".

Another early psychiatrist, E. Bleuler, also noted that there was "a breakdown of the emotions ...The patients appear lazy and negligent because they no longer have the urge to do anything either of their own initiative or at the bidding of another."

This loss of emotion and motivation was later called the "negative symptoms" or "deficit syndrome" of schizophrenia. These negative symptoms include: loss of emotions (blunted or flattened affect), loss of emotional expression, loss of motivation (avolition), loss of social communication (alogia), loss of the drive to be social (increased social withdrawal) and neglect of personal hygiene and dress.

Although antipsychotic medication doesn't decrease negative symptoms once they appear; staying on antipsychotic medication appears to often prevent these negative symptoms from developing or getting worse.

A few research studies have found that combination therapy with antipsychotic plus antidepressant medication is an effective treatment for the negative symptoms of schizophrenia (with a Number Needed To Treat [NNT] =3 which is a robust clinical finding).

The prevalence of negative symptoms or deficit syndrome is approximately 15% in first-episode patients and 25%-30% in chronic schizophrenia.

Precipitants

In genetically vulnerable individuals, certain illicit drugs, especially cannabis ("pot"), have been shown to trigger Schizophrenia. However, for the majority of individuals with Schizophrenia, the cause of this disorder is unknown.

Psychological Complications

Individuals with this disorder may develop significant loss of interest or pleasure. Likewise, some may develop mood abnormalities (e.g., inappropriate smiling, laughing, or silly facial expressions; depression, anxiety or anger).

Often there is day-night reversal (i.e., staying up late at night and then sleeping late into the day).

The individual may show a lack of interest in eating or may refuse food as a consequence of delusional beliefs. Often movement is abnormal (e.g., pacing, rocking, or apathetic immobility).

Frequently there are significant cognitive impairments (e.g., poor concentratiion, poor memory, and impaired problem-solving ability). The majority of individuals with schizophrenia are unaware that they have a psychotic illness. This poor insight is neurologically caused by illness, rather than simply being a coping behavior. This is comparable to the lack of awareness of neurological deficits seen in stroke patients.

This poor insight predisposes the individual to noncompliance with treatment and has been found to be predictive of higher relapse rates, increased number of involuntary hospitalizations, poor functioning, and a poorer course of illness.

Depersonalization, derealization, and somatic concerns may occur and sometimes reach delusional proportions. Motor abnormalities (e.g., grimacing, posturing, odd mannerisms, ritualistic or stereotyped behavior) are sometimes present.

Tragically, 5% die due to suicide. The suicide risk is highest at the onset of the illness.

The life expectancy of individual with schizophrenia is shorter than that of the general population for a variety of reasons. Suicide is an important factor, because approximately 5% of individuals with Schizophrenia commit suicide - and between 20% and 40% make at least one suicide attempt.

The majority of psychotic individuals are never at risk of harming themselves or others. However, a small minority of individuals with schizophrenia become violent. The major predictors of violent behavior are male gender, younger age, past history of violence, noncompliance with antipsychotic medication, and excessive substance use.

In a psychiatric emergency, every effort should be made to call the patient's psychiatrist before calling the police. If the police arrive without being accompanied by a psychiatrist and ambulance; there is a risk of tragedy (being shot) if a psychotic individual physically threatens the police.

Medical Complications

Schizophrenia shortens lifespan by up to 15 years, primarily due to cardiovascular disease, and this excess mortality is getting worse.

In India the mean age at death was 34.2 years, which is well below the national average life span of 60.5 years.

Cardiovascular risk increases after first exposure to any antipsychotic drug. Smoking and obesity are also major risk factors for this excess mortality.

Outcome

The best outcomes are associated with early and persistent treatment with antipsychotic medication soon after the onset of schizophrenia.

Other factors that are associated with a better prognosis include good premorbid adjustment, acute onset, later age at onset, good insight, being female, precipitating events, associated mood disturbance, brief duration of psychotic symptoms, good interepisode functioning, minimal residual symptoms, absence of structural brain abnormalities, normal neurological functioning, a family history of Mood Disorder, and no family history of Schizophrenia.

Outcome of Schizophrenia

Schizophrenia Recovery At 10-Year Follow-up Compared To Other Disorders

Recovery and Relapse In Schizophrenia

The topic of recovery in Schizophrenia is very controversial. There are many dishonest recovery claims made about vitamins or treatments that "cure Schizophrenia". For more about recovery in Schizophrenia, (click here)

Associated Laboratory Findings

No laboratory or psychometric test is diagnostic of this disorder.

However, individuals with schizophrenia often have a number of (non-diagnostic) neurological abnormalities. They have enlargement of the lateral ventricles, decreased brain tissue, decreased volume of the temporal lobe and thalamus, a large cavum septum pellucidi, and hypofrontality (decreased blood flow and metabolic functioning of the frontal lobes).

They also have a number of cognitive deficits on psychological testing (e.g., poor attention, poor memory, difficulty in changing response set, impairment in sensory gating, abnormal smooth pursuit and saccadic eye movements, slowed reaction time, alterations in brain laterality, and abnormalities in evoked potential electrocephalograms).

Prevalence

Schizophrenia is the fourth leading cause of disability in the developed world (for ages 15-44), and Schizophrenia is observed worldwide. The median lifetime prevalence of Schizophrenia is 0.48% (i.e., 1,542,922 Americans).

The incidence of Schizophrenia is slightly higher in men than women. Negative symptoms (e.g., social withdrawal, lack of motivation, flat emotions) tend to predominate in men; whereas depressive episodes, paranoid delusions, and hallucinations tend to predominate in women.

In 2002, the overall cost of Schizophrenia in America was estimated to be USD $62.7 billion.

Comorbidity

Alcoholism and drug abuse worsen the course of this illness, and are frequently associated with it. From 80% to 90% of individuals with Schizophrenia are regular cigarette smokers.

Anxiety and phobias are common in Schizophrenia, and there is an increased risk of Obsessive-Compulsive Disorder and Panic Disorder.

Schizotypal, Schizoid, or Paranoid Personality Disorder may sometimes precede the onset of Schizophrenia.

Several studies have found surprisingly high co-occurrence of Schizophrenia Spectrum Disorder with Dissociative Disorders.

    "Between 9% and 50% of Schizophrenia Spectrum patients also meet diagnostic criteria for a Dissociative Disorder. One study showed that in a sample of patients diagnosed with Dissociative Identity Disorder 74.3% also met diagnostic criteria of a Schizophrenia Spectrum Disorder, 49.5% met diagnostic criteria for Schizoaffective Disorder, and 18.7% met diagnostic criteria for Schizophrenia. In addition, patients with a Dissociative Disorder have often had a previous diagnosis of a Schizophrenia Spectrum Disorder (between 27% and 41%)."

Familial Pattern

The first-degree biological relatives of individuals with Schizophrenia have a risk for Schizophrenia that is about 10 times greater than that of the general population.

Concordance rates for Schizophrenia are higher in monozygotic (identical) twins than in dizygotic (fraternal) twins. The existence of a substantial discordance rate in monozygotic twins also indicates the importance of environmental factors.

Effective Therapies

Most Need Lifelong Antipsychotic Medication

The most current treatment guidelines for Schizophrenia recommend only 1 year of maintenance therapy after the first psychotic episode, and 5 years of maintenance therapy after multiple psychotic episodes.

Yet followup of individuals with first episode Schizophrenia has shown that two-thirds relapse within 1 year and almost 90% relapse within 2 years. Numerous research studies have confirmed that individuals with first episode Schizophrenia have a marked decrease in overall cognitive abilities, and that Schizophrenia has a poor outcome.

  • If virtually all individuals with Schizophrenia relapse into psychosis off antipsychotic medication

  • If each psychotic relapse further increases cognitive impairment

  • If untreated Schizophrenia has a poor outcome

  • Then it is only logical to continue antipsychotic medication lifelong in order to prevent psychotic relapses and worsening of cognitive impairment

To better understand this, consider the stroke patient who is having a series of small strokes. After each small stroke, the patient makes a partial recovery, but never fully recovers. Thus, the patient's overall neurological functioning decreases with each additional small stroke. That's why every effort must be made to stop the return of these strokes. Unfortunately, after a severe stroke, the damage may be so great that there is no recovery.

The same is true for psychotic episodes in Schizophrenia. After every small psychotic episode, when restarted on antipsychotic medication, the person with Schizophrenia makes a partial recovery, but never fully recovers. Thus that person's cognitive functioning decreases with each additional small psychotic episode. That's why every effort must be made to stop the return of these psychotic episodes. Unfortunately, after a severe psychotic episode, the cognitive damage may be so great that there is no recovery.

Overview of Effective Therapies

  • Since Schizophrenia is a lifelong brain disorder which usually results in unemployment and social isolation; governments should ensure that there is adequate mental health funding for: disability pensions, government subsidized housing, supervised psychiatric group homes, free psychiatric medication and healthcare, mental health drop-in centers and clubhouses, sheltered employment, and supervised recreational activities.

  • It is now obvious that there will not be a "quick cure" for Schizophrenia. Our best therapies can protect our patients from further harm, and significantly improve their quality of life. These therapies can ensure that most of our patients will have an active social life. Unfortunately, our current therapies are unable to return the majority of our patients to competitive employment.

  • Worldwide, between 10%-20% of individuals with Schizophrenia live normal lives if they stay on their antipsychotic medication. The remainder of individuals with Schizophrenia have to adjust to being unable to return to work, and being less socially active. Thus it is essential that individuals with Schizophrenia be offered rewarding opportunities for volunteer work and community involvement.

  • "Recovery" in Schizophrenia must be defined as both functional (occupational & social) recovery as well as symptomatic recovery. Thus successful treatments for Schizophrenia must show that they decrease: unemployment, social isolation, medical adverse effects, psychotic relapse, hospitalization, and suicide. Unfortunately, apart from antipsychotic medication, most of the other treatments for Schizophrenia haven't consistently shown that they bring about both functional and symptomatic recovery.

  • Early diagnosis and lifelong treatment on antipsychotic medication is absolutely essential for recovery from Schizophrenia. Therapists must insist that all patients faithfully stay on their antipsychotic medications. Those that find it difficult to stay on oral medication should be switched to long-acting injectable antipsychotic medication. "Drug holidays" almost always turn out to be a disaster.

  • Unfortunately, when the cognitive impairment becomes severe enough, individuals lose their ability to recognitive that they are psychotic. They then refuse treatment and tragedy soon follows.

  • Individuals smoking marijuana (cannabis), abusing alcohol or other drugs do not make a full recovery from Schizophrenia.

  • One of the worst aspects of Schizophrenia is its loneliness. Many individuals with Schizophrenia lose their job, their friends, and their feeling of self-worth. Antipsychotic medication can't remedy these losses; hence therapists must organize social activities that restore friends, self-worth and laughter.

  • Most patients prefer activities that last only a few hours; rather than activities that last for days. Thus activities like: day-trips, volleyball, craft groups, art groups, choir, cooking groups, movie groups, walking groups, hiking/snowshoeing groups or coffee get-togethers are preferred over longer, more stressful activities (e.g., week-long trips).

  • Patients should vote on what activities they want, and how these activities should be run. For safety reasons; it is wise to not include an overtly psychotic patient in these recreational activities. Refreshments should be provided at half time, so that patients can sit and socialize with other patients. These supervised activities often provide patients with the only social contact and laughter that they have all week. (On a patient's birthday, my wife always remembered to bring a birthday cake to our activities.)

  • Family members should be invited to join the patient's appointments (if the patient approves).

  • If a psychotic patient is undergoing significant deterioration, or is at risk of harming himself or others; family or concerned friends should be permitted to speak to the therapist - even against the expressed wishes of the psychotic patient. A family member's or friend's right to get psychiatric help for a psychotic loved one who is relapsing should supersede a psychotic patient's right to medical confidentiality.

  • Psychotic individuals should be (voluntarily or involuntarily) hospitalized when they suffer severe deterioration in functioning. Patients should not have to wait until they are "at risk of harming self or others" before psychiatric help is given.

  • Unfortunately, only a few legal jurisdictions (e.g., British Columbia, Canada) have Mental Health Acts that permit involuntary hospitalization on the basis of severe deterioration in functioning. Most legal jurisdictions have Mental Health Acts that permit involuntary hospitalization only when the psychotic patient "is at risk of harming self or others". Such antiquated Mental Health Acts prevent many families from getting psychiatric help for their psychotic loved ones, until it is too late.

  • High rates of rehospitalization can be dramatically reduced if there is continuity of care. When patients are acutely psychotic; they should be seen by their outpatient therapist for one hour every week. Once they are stabilized; the frequency of their outpatient visits should be gradually decreased. Finally, they should be seen for one hour at least once every 3-6 months for the rest of their lives. (This is exactly what I did in my private psychiatric practice, and very few of my patients required rehospitalization.)

Pharmacotherapy

Antipsychotic medication shortens the duration of psychosis in Schizophrenia, and prevents recurrences (but psychotic relapses can still occur under stress). Usually it takes years before individuals can accept that they have Schizophrenia and need medication. When individuals stop their antipsychotic medication, it may take months (or even years) before they suffer a psychotic relapse. Most, however, relapse within weeks. After each psychotic relapse there is increased cognitive impairment.

Antipsychotic medication (+/- antidepressant medication +/- antianxiety medication) usually prevents suicide, minimizes rehospitalization, and dramatically improves social functioning. Unfortunately, even on antipsychotic medication, most individuals with Schizophrenia can't return to gainful employment due to the emotional, motivational, and cognitive deficits caused by this illness.

Lifelong treatment with antipsychotic medication is essential for recovery from Schizophrenia. Individuals also require long-term emotional and financial support from their families. Most individuals with Schizophrenia qualify for government (or insurance) disability pensions. Social rehabilitation (e.g., club-houses, supervised social activities) and sheltered/volunteer employment are also essential.

Research has shown that: (1) the newer, "atypical" or "second generation", antipsychotic medications are no more effective than the first generation antipsychotic medications; (2) most antipsychotic medications are equally effective, but only differ in adverse effects; (3) half of patients refuse to stay on their antipsychotic medication - and this is a major reason for treatment failure; (4) antipsychotic medication is effective in symptom control in up to two-thirds of patients, but in at least one-third of patients the response is poor; (5) antipsychotic medications are the most effective means of preventing relapse and rehospitalization, and should be taken continuously for a lifetime (since 90% of first-episode patients with Schizophrenia relapse within 2 years if not on antipsychotic medication).

Antipsychotic Effectiveness

Equal Effectiveness Of Antipsychotic Drugs In Treating Hallucinations

Thus antipsychotic medication is not a cure for Schizophrenia, but these drugs significantly help to control Schizophrenia.

A review of 65 randomised controlled trials involving 6493 patients with Schizophrenia found that, at 1-year follow-up:

  • Antipsychotic drugs prevent relapse (relapse rate: drug 27%, placebo 64%, NNT 3)

  • Antipsychotic drugs prevent hospitalization (hospitalization rate: drug 10%, placebo 26%, NNT 5)

  • More participants in the placebo group than in the antipsychotic drug group left the studies early due to inefficacy of treatment (left prematurely: drug 20%, placebo 50%, NNT 3)

  • Quality of life was better in antipsychotic drug-treated participants (SMD -0.62)

Antipsychotic medication decreases the risk of violent behavior in individuals with Schizophrenia. Clozapine has a specific anti-aggressive effect in Schizophrenia.

Because olanzapine causes very significant weight gain; it is not a first-line treatment for Schizophrenia.

For individuals with Schizophrenia who refuse to take their antipsychotic medication, there is the option of giving them injections of long-lasting antipsychotic medication (that can last one month).

Clozapine is often effective for patients that have failed to respond to two previous antipsychotic medications. In combination with antipsychotic medication, mood stabilizers are used to control mood swings and impulsivity, and antidepressants are used to treat depression.

"Drug holidays" are usually disastrous; thus it is essential that medication be taken continuously without significant dose reduction.

Often involuntary hospitalization with forced medication saves lives. There is a wonderful article written by a neuroscientist telling how, when she developed Schizophrenia, "Forced medication saved my life".

Electroconvulsive Therapy

Electroconulsive therapy (ECT) may provide months of benefit, but this benefit is not sustained.

Psychotherapy

No therapy is a substitute for antipsychotic medication, but a number of psychological and social therapies do increase the effectiveness of antipsychotic medication.

Cognitive behavioral therapy (CBT) is mildly effective against hallucinations (with small effect sizes ranging from 0.35 to 0.44). CBT appears to be no more effective than other, less expensive, social therapies.

Other effective psychological treatments include: psychoeducation, assertive community treatment, supported employment, skills training, token economy interventions, and family-based psychosocial intervention.

Intensive case management (ICM) reduces hospitalization, improves adherence to care, and improves social functioning.

Educating the patient and the patient's family about schizophrenia and its treatment is always beneficial. Whenever possible, the patient's family should be included and supported in the patient's therapy. The more psychotic the patient, the greater is the need for family involvement in treatment.

Research on cognitive remediation therapy for schizophrenia has shown the treatment effect is small and disappears at follow-up assessment.

Ineffective therapies

There are many ineffective therapies that promise miracle-like recovery from schizophrenia with vitamins or other treatment fads. These ineffective therapies can have an initial placebo effect.

Niacin (vitamin B3), the main vitamin used in the bogus mega-vitamin therapy for schizophrenia, has proven to be deadly, hence has been banned.

Vitamins, dietary supplements, computer-assisted cognitive rehabilitation, and playing computerized brain training games have all proven to be ineffective in improving occupational or psychosocial functioning, decreasing psychotic symptoms, or preventing relapse in schizophrenia.

Research on computer-assisted cognitive rehabilitation and computerized brain training games has shown that, like playing checkers, game performance does improve with practice, but this doesn't translate into clinically significant improvement in: work or social functioning, psychotic symptoms, or prevention of rehospitalization.

WARNING: Cannabis And Psychosis

Cannabis (pot) has been proven to nearly quadruple the risk of developing schizophrenia.

In 1969-70, Swedish military conscripts (49,321 males representing >97% of the country's male population aged 18-20) were followed for 35 years.

At the start of this study, none of the conscripts had schizophrenia. Over 35 years, those who had used cannabis more than 50 times at the beginning of the study had 3.7 times the normal rate of developing schizophrenia. This association was not explained by use of other psychoactive drugs or personality traits.

Schizophrenia normally occurs in 1% of the population. 86% of individuals with schizophrenia are disabled and unemployed. Thus this research would suggest that legalizing cannabis could triple the incidence of schizophrenia in regular cannabis smokers. This would cause a massive increase in the national unemployment rate.

WARNING: Cannabis And Lung Cancer

Swedish scientists did a 40 year followup study of 97% of all Swedish males, aged 18-20, entering the Swedish army in 1969-70 (a total of 49,321 males). Participants were tracked until 2009 (i.e., age 58-60) for lung cancer using the computerized Swedish national health registry.

For those males entering the army at age 18-20 that reported using cannabis more than 50 times; there was a twofold increase in the rate of lung cancer. It should be noted that most lung cancer occurs after age 60; thus this twofold increase probably underestimates the lifetime cancer risk from smoking cannabis.

For males, lung cancer is the most common form of cancer. Thus this research would suggest that legalizing cannabis could double the incidence of lung cancer in regular cannabis smokers.

WARNING: Legalizing Illicit Drugs

Some people argue that illicit drugs should be legalized to decrease the crime associated with these drugs. Historically, tobacco and alcohol were once illegal drugs.

Tobacco smoking is now the leading cause of death in America, and alcoholism is the third leading cause of death. Thus legalizing illicit drugs does not make them any less medically and socially harmful. In fact the opposite is true; legalizing illicit drugs increases their use and the harm they cause.

The Government of Finland is passing legislation that will gradually ban all tobacco use by 2040.



Scientists Show Link Between Cannabis And Schizophrenia




Cannabis Found To Decrease Brain Connections




New, deadly form of cannabis




Pot is 4 times more potent than in 1970s, and more toxic


Trustworthy Research (PubMed.gov)


A Dangerous Cult


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Videos






WebMD: A Visual Guide to Schizophrenia


Stories

Rating Scales

Lack Of Social Skills During Schizophrenia

There are certain social skills that are essential for healthy social functioning. During untreated Schizophrenia, individuals may develop schizoid personality traits; thus lack the essential social skills of intimacy, sociability, and emotional expressiveness.

    Social Skills That Are Lacking In Schizophrenia With Schizoid Personality Traits

    SOCIAL SKILL NORMAL SCHIZOID TRAITS
    Intimacy Wanting close friendships or intimate romantic relationships Intimacy avoidance
    Sociality Friendly; interested in social contacts and activities Social withdrawal
    Emotional Expressiveness Normal range of emotional experience and expression Lack of emotional expression
    Enthusiasm Being enthusiastic, interested, motivated Loss of interest or pleasure

During untreated Schizophrenia, individuals may also develop paranoid personality traits; thus lack the essential social skills of trust, forgiveness, and gratitude.

    Social Skills That Are Lacking In Schizophrenia With Paranoid Personality Traits

    SOCIAL SKILL PARANOID TRAITS NORMAL
    Trust Suspiciousness Trusting the loyalty and good intentions of significant others (e.g., family, friends)
    Forgiveness Bearing grudges Forgiving other people's mistakes; not bearing grudges or seeking revenge
    Gratitude Feeling victimized Being thankful for the good things in life; expressing thanks to others

Brain Changes In Schizophrenia

Cognitive impairment, especially of verbal memory and processing speed, is a core feature of Schizophrenia. What brain changes could cause these cognitive impairments?

Research has found that there are progressive brain changes during the early phases of psychosis. Structural alterations in medial temporal, prefrontal, anterior cingulate and insular cortex plus superior temporal gyrus volume reductions often occur during the acute process of transition to psychosis. These brain structural changes show marked progression at the initial stage of Schizophrenia, but less in chronic Schizophrenia.

"In the development of Schizophrenia, the earliest structural deficits in the brain are found in parietal brain regions, supporting visuospatial and associative thinking. Over 5 years, these deficits progress anteriorly into temporal lobes, engulfing sensorimotor and dorsolateral prefrontal cortices, and frontal eye fields.

These structural deficits in the brain correlate with psychotic symptom severity and mirror the neuromotor, auditory, visual search, and frontal executive impairments in the disease. In temporal regions, gray matter loss is completely absent early in the disease but becomes pervasive later. Later, the dorsolateral prefrontal cortex and superior temporal gyri, develop structural deficits that are found consistently in adult studies.

These structural deficits of the brain were found to be independent of antipsychotic therapy." Overall, the findings suggest continuous progressive brain tissue decreases and lateral ventricle volume increases in chronically ill patients, up to at least 20 years after their first symptoms.

Progressive volume loss seems most pronounced in the frontal and temporal (gray matter) areas. Progressive lateral ventricle volume increases are also found. More pronounced progressive brain changes in patients is associated with poor outcome, more negative symptoms, and a decline in neuropsychological performance in one or some of the studies, but not consistently so.

Higher daily cumulative dose of antipsychotic medication intake is either not associated with brain volume changes or with less prominent brain volume changes. "In patients with Schizophrenia as a group, higher illness severity was associated with frontotemporal gray matter reduction and frontoparietal white matter expansion in both brain hemispheres."

Insula-Frontal Lobe


Articles On Weight Gain

  • The Metabolic Effects of Antipsychotic Medications - Canadian Journal of Psychiatry July 2006

    • (Editor: At least a decade ago, clinicians became alarmed by the 20 to 40 lb weight gains experienced by many of our patients on the newer antipsychotic medications [especially clozapine, olanzapine, and to a lesser extent, respiridone and quetiapine]. Many older, equally effective, antipsychotic medications [e.g., flupenthixol, sulpiride, amisulpiride] had much less, or no, weight gain. Initially, the manufacturers of these newer, obesity-inducing antipsychotic medications assured clinicians that the weight gain on their medications was minimal. Now, many years later, researchers have finally acknowleged the full magnitude of this serious weight gain problem. My question is why did pharmaceutical company sponsored researchers and lecturers minimize this serious weight gain problem for so long?)

  • Metabolic Monitoring for Patients Treated With Antipsychotic Medications - Canadian Journal of Psychiatry July 2006

    • (Editor: It now is essential that clinicians follow these guidelines to metabolically monitor their patients on obesity-inducing antipsychotic medications.)

  • Pharmacologic and Nonpharmacologic Strategies for Weight Gain and Metabolic Disturbance in Patients Treated With Antipsychotic Medications - Canadian Journal of Psychiatry July 2006

    • (Editor: The best way, in my opinion, to avoid weight gain on antipsychotic medications is to: (1) use antipsychotic medications which cause minimal weight gain [e.g., flupenthixol, aripiprazole, loxapine, sulpiride, amisulpiride], (2) minimize sugar and starch in the diet, and (3) walk briskly 30 minutes per day. Unfortunately, not all patients respond to the antipsychotics which cause minimal weight gain; hence must be tried on other antipsychotic medications which induce obesity. Nevertheless, many patients on these obesity-inducing medications normalize their weight following steps #2 and #3.)

Books

Famous People With Schizophrenia

Medical


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Diagnostic Features of Schizophrenia

ABNORMAL BIG-6 DIMENSION OF MENTAL ILLNESS EPISODIC OR CONTINUOUS "POSITIVE SYMPTOMS" CONTINUOUS "NEGATIVE SYMPTOMS"
IMPAIRED INTELLECT: Being intellectually impaired or psychotic.
Impaired Reasoning
Perceptual Dysregulation
Unusual Beliefs or Experiences
Disorganized Speech or Behavior
DETACHMENT: Being detached, unassertive, and unenthusiastic.
Loss of Interest or Pleasure
Social Withdrawal
Intimacy Avoidance
Restricted Emotions


(Note: Recovery = symptomatic remission + full-time gainful employment + weekly contact with friends)




Schizophrenia F20 - ICD10 Description, World Health Organization
The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time.

The most important psychopathological phenomena include thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussing the patient in the third person; thought disorders and negative symptoms.

The course of schizophrenic disorders can be either continuous, or episodic with progressive or stable deficit, or there can be one or more episodes with complete or incomplete remission.

The diagnosis of Schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedate the affective disturbance. Nor should Schizophrenia be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal.

Similar disorders developing in the presence of epilepsy or other brain disease should be classified under F06.2 (organic delusional disorder), and those induced by psychoactive substances under F10-F19 (mental and behavioural disorders due to substance abuse) with common fourth character .5 (psychotic disorder).

    F20.0 Paranoid Schizophrenia

    Paranoid Schizophrenia is dominated by relatively stable, often paranoid delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances.

    Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.

    F20.1 Hebephrenic Schizophrenia

    A form of Schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behavior irresponsible and unpredictable, and mannerisms common. The mood is shallow and inappropriate, thought is disorganized, and speech is incoherent.

    There is a tendency to social isolation. Usually the prognosis is poor because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults.

    F20.2 Catatonic Schizophrenia

    Catatonic Schizophrenia is dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods.

    Episodes of violent excitement may be a striking feature of the condition. The catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic hallucinations.

    F20.3 Undifferentiated Schizophrenia

    Psychotic conditions meeting the general diagnostic criteria for Schizophrenia but not conforming to any of the subtypes in F20.0-F20.2, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics.

    F20.4 Post-schizophrenic depression

    A depressive episode, which may be prolonged, arising in the aftermath of a schizophrenic illness.

    Some schizophrenic symptoms, either "positive" or "negative", must still be present but they no longer dominate the clinical picture.

    These depressive states are associated with an increased risk of suicide.

    If the patient no longer has any schizophrenic symptoms, a depressive episode should be diagnosed (F32.-). If schizophrenic symptoms are still florid and prominent, the diagnosis should remain that of the appropriate schizophrenic subtype (F20.0-F20.3).

    F20.5 Residual Schizophrenia

    A chronic stage in the development of a schizophrenic illness in which there has been a clear progression from an early stage to a later stage characterized by long- term, though not necessarily irreversible, "negative" symptoms, e.g. psychomotor slowing; underactivity; blunting of affect; passivity and lack of initiative; poverty of quantity or content of speech; poor nonverbal communication by facial expression, eye contact, voice modulation and posture; poor self-care and social performance.

    F20.6 Simple Schizophrenia

    A disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. The characteristic negative features of residual Schizophrenia (e.g. blunting of affect and loss of volition) develop without being preceded by any overt psychotic symptoms.


Schizophrenia - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with Schizophrenia needs to meet all of the following criteria:

  • Active-Phase Symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these symptoms must be delusions, hallucinations, or disorganized speech:

    • Delusions.

    • Hallucinations.

    • Disorganized speech (e.g. frequent derailment or incoherence).

    • Grossly disorganized or catatonic behavior.

    • Negative symptoms (i.e., diminished emotional expression or avolition).

  • For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

  • Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet the above criterion for active-phase symptoms and may include periods of prodromal or residual symptoms.

    During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more active-phase symptoms present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

  • Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

  • If there is a history of autistic spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of Schizophrenia, are also present for at least 1 month (or less if successfully treated).


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Schizophrenia Disorder (like Bipolar Disorder and Schizopaffective Disorder) has a high risk of suicide; hence the following treatment protocal for suicide is important.







The following are general principles applicable to the treatment of every disorder.











Goals of Therapy

Individuals with schizophrenia and their families have defined that recovery from schizophrenia should involve:

  • Functional (occupational and social) remission:

    • "Employment/education: Returning to work/school/homemaking."

    • "Fulfilment of duties and responsibilities: Sons or daughters being loving, helping with housework, and attending social gatherings. In addition, husbands financially supporting their families, and wives taking care of their children and doing the expected homemaking."

    • "Independent functioning: Taking care of their personal needs without being dependent on or having the help/assistance of others."

    • "Social functioning: Socializing and having meaningful interpersonal relationships: having social skills (having manners, e.g., greeting others); having friends to talk to or spend time with; attending and participating in family and social functions; getting married; being reunited with or repairing broken relationships with spouses and family members."

  • Symptomatic remission:

    • "Symptom control: Eliminating hallucinations (hearing voices), delusions, negative emotion (fear) and the aches and pains caused by schizophrenia. In addition, their caretakers want elimination of the anger, physical abuse, wandering and inappropriate laughter caused by schizophrenia."

    • "Cognitive ability: Overcoming cognitive impairment: being less confused; being able to remember things and being less forgetful (e.g., with respect to their day to day tasks); being able to concentrate on or pay attention to their work, household tasks or to conversations with other people; and being alert, with a sharp mind."

    • "Activity: Overcoming apathy (a core feature of schizophrenia) by: "not being lazy or sleeping all the time"; following a routine (e.g., waking up/eating on time); exercising and being fit; keeping busy (e.g., pursuing hobbies such as reading or making handicrafts); being engaged in some form of productive tasks (e.g., cooking, cleaning or other housework) and performing these satisfactorily."

    • "Self-care: Taking care of their own health and maintaining good hygiene practices. Examples include taking medicines on their own without being persuaded or reminded to; informing others when feeling unwell; sleeping well and having healthy eating habits (e.g., having a good appetite and eating proper meals); bathing regularly and being clean; taking care of personal and household belongings; not smoking cigarettes or inhaling tobacco; and maintaining a neat and groomed appearance by combing one's hair and dressing appropriately."

    • "Overcoming negative personality traits" (to be less schizoid or paranoid): "Being less socially withdrawn and insensitive; being more self-confident; being less suspicious; not bearing grudges or feeling victimized."

    • "Reduced side-effects: (Antipsychotic medications do differ significantly in their side-effects; hence it is possible to reduce side-effects.)"

    • "Management without medication: (Unfortunately this is not possible because of the high relapse rate off of antipsychotic medication.)"


Treatment

Treatment Guidelines

Treatment

Summary Of Clinical Practice Guidelines Treatment Of Schizophrenia - Canadian Psychiatric Association (2005)

Initial Assessment

    The initial assessment should include inquiries specifically directed to the following:

    • Positive symptoms such as hallucinations and delusions

    • Negative symptoms such as flat or blunted affect, poverty of thought or thought content, and avolition
    • Disorganization such as thought disorder, inappropriate affect, and disorganized behavior

    • Affective symptoms such as anxiety or depression, particularly in relation to the psychotic symptoms

    • Suicidal or aggressive thinking and behavior, impulsivity, because any risk for suicide or violence has implications for where the patient should be assessed and treated

    • The time of onset or exacerbation of symptoms and the context and possible precipitating factors

    • Substance use and abuse in relation to the onset and persistence of psychotic and associated symptoms

    • The current living situation, including housing, finances, social supports, ADLs, social activity, school, and work

    • A mental status examination, including office or bedside assessment of cognitive function, based on data from all sources of information, in which positive and negative findings should be documented, since they may change over time

    • A physical examination, including neurologic examination, and laboratory tests, including screening toxicology

    • A general medical history and review of symptoms

    • Neuropsychological testing is suggested in patients with first-episode psychosis and those with poor response to treatment

      • Schizophrenia is associated with significant cognitive impairment, which is associated with poor functional recovery.

    • Clinical features suggestive of chromosome 22q11 syndrome should be evaluated in patients with schizophrenia and laboratory testing obtained when indicated

      • Chromosome 22q11 deletion is associated with schizophrenia.

    • Computed tomography or magnetic resonance imaging at illness onset and in patients with refractory illness should be done

      • Patients with schizophrenia have an increased prevalence of structural brain abnormalities.

    • Regular clinical and laboratory monitoring for movement disorders, obesity, diabetes, hyperlipidemia and sexual dysfunction indicated in patients with schizophrenia

      • Patients with schizophrenia have reduced life expectancy; the combination of illness and the effects of antipsychotic treatment place patients at risk of movement disorders, obesity, diabetes, hyperlipidemia, and sexual dysfunction.

Pharmacotherapy

  • General Principles
    • Pharmacotherapy with antipsychotic medications is an essential component of a treatment plan for most patients with schizophrenia.

    • Psychosocial interventions work synergistically with medication to optimize treatment adherence and successful community living.

    • Medications must be individualized because the individual response is highly variable. Consideration should be given to the immediate presenting problem and the patient's prior response to pharmacotherapy, including efficacy and side effects. Patients with a first episode of psychosis usually require a lower dosage, as do the elderly.

    • Patients must be involved in decisions and choices for pharmacotherapy. This includes being provided with information on the risks and benefits of both taking and not taking medications. However, because a high level of benefit is achieved with medication, it should be recommended assertively, and patients' agreement in taking mediation should be sought actively.

    • Side effect profiles vary according to the duration of drug exposure, the evolution of the disorder, and the patient's general health.

    • Simple medication regimens, such as once-daily dosing, promote adherence to treatment.

    • Dosages should be maintained within the recommended range, and reasons for going outside the range should be clearly documented and justified.

    • Using more than one antipsychotic simultaneously is not supported by available evidence.

    • Regular and ongoing evaluations are equally necessary when patients respond to medications, when they fail to respond, and when they develop side effects. Standardized scales are useful tools for baseline and later assessments.

    • Research has not found clear and consistent differences between typical antipsychotic medications and atypical antipsychotic medications in regard to treatment response for positive symptoms, with the notable exception of clozapine for treatment-resistant patients.

    • Atypical antipsychotic medications induce fewer neurologic side effects (that is, EPSEs or tardive dyskinesia [TD]) but have a greater propensity for metabolic side effects (that is, weight gain, diabetes mellitus, dyslipidemia, or metabolic syndrome).

  • Pharmacotherapy For The Acute Phase Of Schizophrenia
    • The assessment in the acute phase should be as comprehensive as possible under the circumstances.

    • Particular attention needs to be paid to the potential for danger to self or others.

    • Engagement with the patient in the acute phase is facilitated by acknowledging his or her experiences, providing clear simple communication, and including family and supports where possible. Explaining the patient's rights and any legal process is essential.

    • Pharmacologic treatment should be initiated as soon as possible, and the risks and benefits of pharmacotherapy should always be explained.

    • All these principles apply in emergency situations, but emergency medication strategies are available to contain the patient and maintain staff safety.
    • Pharmacotherapy For Emergency Treatment

      • Verbally engaging an agitated patient should always be tried in the setting of an appropriately safe emergency room envi- ronment with available security personnel.

      • Oral medications should be offered and, if accepted, can be as effective as IM medications. The rapid-dissolving forms of some atypical antipsychotic medications may have benefits for treatment in emergency situations because it is easier to confirm compliance.

      • When necessary to preserve patient and staff safety, restraint measures should be taken by a trained team following an approved protocol.

      • Historically, IM haloperidol has been the most widely used treatment for agitated patients with psychosis. The combination of haloperidol 5 mg IM with lorazepam 2 mg IM has been shown to be more effective than haloperidol alone.

      • Olanzapine 2.5 mg to 10 mg IM has been demonstrated to be as effective as haloperidol alone. 10 mg IM is the most frequently prescribed single dosage. Combining IM olanzapine with IM benzodiazepine should be avoided because cardiac and respiratory difficulties, including fatalities, have been associated with this combination.

      • Oral solution or rapid-dissolving tablets of either risperidone or olanzapine are as effective as haloperidol IM.

      • Zuclopenthixol acetate IM for the treatment of acute agitation is just as effective as these other treatments. However, fewer injections of zuclopenthixol are needed since one injection lasts 2-3 days.

      • When medications are being started or changed, follow-up visits for outpatients need to be frequent (weekly intervals), but they maybe much less frequent when the medication is established in terms of dosage, response, and side effects and when the patient is stable.

    • Pharmacotherapy For Nonemergency Treatment

      • When appropriate, thepatientandcare- givers need to be engaged in the treatment process and provided with information and options.

      • It may be possible to engage the patient in treatmentfrom the perspective of his or her concerns for secondary symptoms such as depression, anxiety, or insomnia, rather than from the perspective of the primary symptoms of psychosis.

    • Pharmacotherapy For First Episode of Illness With No Prior Treatment

      • Many patients experiencing a first episode of psychosis can be treated at home if safety and support issues are addressed.

      • Benzodiazepines may be adequate to control agitation while initiating a low dosage with slow titration of an antipsychotic medication.

      • Low initial dosages of the medication should be used and titrated at not less than weekly intervals if the clinical situation is not emergent.

      • Avoidance of side effects early in treatment is important for later adherence to treatment.

      • Dosages beyond the recommended range should be restricted to exceptional circumstances only.

    • Pharmacotherapy For Multiple-Episode Patient

      • Obtain a medication history with a view to evaluating drug response and adverse events. It is important to consider the patient's preferences about drugs and route of administration.

      • Titrate up to an initial target dosage (in 1 to 2 weeks in most cases) and monitor for side effects while awaiting an initial response.

      • An adequate trial of 4 to 8 weeks duration on the maximum tolerated dosage within the recommended range.

      • Akathisia can be misinterpreted as psychotic agitation; if the patient is not responding to acute treatment with an antipsychotic, rule out akathisia before administering more antipsychotic medication.

  • Maintenance Pharmacotherapy
    • The goals of pharmacotherapy in this phase are to reduce the intensity and duration of active psychotic symptoms as fully as possible, to minimize side effects, and to promote adherence. Other goals include relapse prevention, minimizing negative and comorbid symptoms, and promoting maximal functional ability.

    • Antipsychotic medications may have to be switched during the maintenance phase. Medications selected for short-term control of agitated behavior during the acute psychotic phase may not be optimal for efficacy and tolerability.

    • Significant and sustained reduction in acute psychotic symptoms often takes 4 to 8 weeks. Improvements in other symptoms and functioning may take much longer. Improvement may continue over 1 year or more of uninterrupted treatment.

    • Premature discontinuation or reduction of antipsychotic medication places the patient at high risk for relapse.

    • The initial treatment response tends to be better in first-episode than in multiple-episode schizophrenia, but adherence tends to be poor.

    • A supportive educational approach is recommended.

    • Whereas depression tends to abate with the remission of psychosis in the multiple-episode patient, it tends to increase for the first 3 months following the first episode.

    • To maintain treatment adherence, it is crucial to have the patient participate in pharmacotherapy and to address individual barriers and resistance to ongoing therapy.

    • Assessments should take place at least every 3 months to achieve optimal dosages and choice of antipsychotic medications and to monitor for drug-induced side effects.

    • There are no predictive factors indicating which patients can safely and permanently discontinue antipsychotic medication. In one of the larger early randomized placebo-controlled studies of maintenance antipsychotics, 62% of the first episode psychosis patients on placebo relapsed over 2 years, compared with 46% of those on maintenance pharmacotherapy.

    • First episode patients who have been in remission on medication for at least 1 to 2 years may be considered candidates for a trial of no medication. Withdrawal of antipsychotic medication should be done slowly over 6 to 12 months.

    • Multiple-episode patients with a minimum of 5 years of stability, without relapse and with adequate functioning, should be observed before a slow withdrawal of antipsychotic medication over 6 to 24 months is considered.

    • Warning by the editor of Internet Mental Health (This Is Not Part Of The CPA Guidelines):

      • Recent research has shown that, for individuals with Schizophrenia, after stopping their antipsychotic medication 79% had a psychotic relapse by 12 months, 94% by 24 months, and 97% by 36 months. Thus, 3 years after stopping antipsychotic medication, only 3% of people with Schizophrenia didn't relapse. My experience (having treated more than 1,000 patients with Schizophrenia) was that stopping antipsychotic treatment for Schizophrenia always eventually resulted in a psychotic relapse, especially for those with a family history of schizophrenia, or a history of suicidality, violence, or the inability to care for themselves. With each psychotic relapse, my patients would develop more permanent disability and eventually all of their antipsychotic medications would stop working.

      • Even assuming that 3% of people with Schizophrenia can stay well off medication; is it worth going medication-free if there is a 97% chance that this will be a disaster?

      • I believe that Schizophrenia, like most chronic diseases, requires indefinite treatment. Psychiatrists accept that Bipolar I Disorder requires indefinite treatment; yet many still don't accept that Schizophrenia requires indefinite treatment. Thus they insist that recovered patients with first episode Schizophrenia have a medication-free trial and subsequent psychotic relapse before they will consider prescribing indefinite treatment with antipsychotic medication. This guarantees that 97% their recovered, first episode patients will needlessly have a second, often more serious, psychotic episode.



    • Eighty percent of patients with first-episode psychosis are at risk for a second episode within the first 3 to 5 years, and recovery from a second episode is slower and often less complete.

    • Despite adequate pharmacotherapy, at least 20% of multiple-episode patients have no positive-symptom response to antipsychotics. A further 30% respond only partially. If poor treatment adherence is a factor, an IM long-acting medication can be considered.

    • Treatment nonresponse to adequate trials of antipsychotics from 2 different classes is an indication for a trial of clozapine.

    • Persistent aggressivity may be helped by a trial of clozapine.

    • Persistent suicidal thoughts or behaviours are an indication that clozapine should be considered.

    • The 4 main pharmacologic strategies for initial nonresponders includeoptimization,substitution, augmentation, and combination.

      • In optimization, the trial of the original antipsychotic is continued with the dosage increased or decreased as appropriate.

      • In the case of no response, substitution can be tried. The antipsychotic is gradually stopped, and another one is introduced with a short period where the 2 antipsychotics overlap.

      • The commonly used augmentation strategies include addition of lithium, anticonvulsants (that is, valproate, carbamazepine, topiramate, and lamotrigine), antidepressants, benzodiazepines, and electroconvulsive therapy (ECT) (but there is limited evidence to support ECT's use).

      • The last strategy is a combination treatment with a second antipsychotic. The efficacy of combined antipsychotic treatment has not been adequately tested.

    • A major depressive episode in the stable phase of schizophrenia is an indication for a trial of an antidepressant.

Psychosocial Interventions

  • General Principles
    • Optimal management requires the integration of medical and psychosocial interventions. Such interventions should not be seen as competing approaches but, in most cases, as necessary complementary interventions to improve clinical symptoms, functional outcome, and quality of life.

    • Effective psychosocial interventions may improve medication adherence, reduce risk of relapse and the need for readmission to hospital, reduce distress resulting from symptoms, improve functioning and quality of life, and provide support for patients, their families, and caregivers.

    • Common comorbid conditions such as substance abuse, anxiety disorders, and depression need to be recognized and addressed with psychosocial interventions.

    • Psychosocial interventions can be best implemented when acute symptomatology has been reduced and the patient can be successfully engaged in treatment.

    • Psychosocial interventions should be adjusted to the stage of the illness and needs of the patients and their families.

    • Listening and attending to the patient's concerns develops empathy, rapport, and a good therapeutic relationship. As well, it can improve engagement and adherence to treatment.

    • Patients, their families, and caregivers should be educated about the course and treatment of the disorder, as well as about ways to reduce risk of relapse. It is also important to provide a realistically hopeful attitude for the future. The physician is an extremely important contributor to this process.

    • The clinical team, the patient, and family members should develop shared, realistic goals for treatment and recovery. Progress toward these goals should be carefully monitored and evaluated.

    • Treatment providers should share plans for early recognition of relapse and crisis response with patient, family, and caregivers.

    • All patients should have access to evidence-based programs that develop skills for activities of daily living, meeting vocational and educational goals, managing finances, developing and maintaining social relationships, and coping with the impact of symptoms.

    • Staff providing psychosocial interventions should be appropriately trained.

  • Cognitive-Behavioural Interventions
  • When applied to schizophrenia and related disorders, the most frequently used cognitive-behavioural interventions include:

    • development of a collaborative understanding of the nature of the illness, which encourages the patient's active involvement in treatment

    • identification of factors exacerbating symptoms

    • learning and strengthening skills for coping with and reducing symptoms and stress

    • reducing physiological arousal

    • testing of key beliefs that may be supporting delusional thinking

    • development of problem-solving strategies to reduce relapse

    • Recommendations
      • Psychoeducation

        • Psychoeducation is an important intervention that needs to be accompanied by training in practical illness management strategies to achieve medication treatment adherence and to prevent relapse.

        • Psychoeducation can improve knowledge about illness, but there are equivocal findings that it increases treatment adherence unless there are also motivational enhancement and behavioural strategies for taking medication as prescribed.

      • Vocational interventions

        • A wide range of possibilities should be considered for patients who are able to work, including volunteer work, supported, or transitional employment.

        • Individuals who suffer from schizophrenia have historically had low rates of employment; meaningful vocational activity, including paid employment, can be positive for individuals' psychological health and quality of life.

        • For many patients it is important to formulate goals for competitive paid employment and, in general, supported employment programs appear to offer the best approach to meeting such goals.

        • Supported employment approaches result in greater success in obtaining competitive paid employment.

      • Skills Training

        • Social skills training should be available for patients who are having difficulty and (or) experiencing stress and anxiety related to social interaction.

        • Social skills training leads to better outcomes with reference to symptoms, social functioning, and quality of life, compared with other standard care and (or) other interventions such as supportive psychosocial intervention and occupational therapy.

        • Life skills training in an evidence-based format should be available for patients who are having difficulty with tasks of everyday living.

        • Life skills training leads to better outcomes with reference to social functioning and quality of life, compared with standard care.

      • Cognitive-Behavioural Interventions

        • Cognitive therapy should be offered to treatment-resistant patients.

        • Randomized controlled studies have shown benefits of CBT for patients with treatment-resistant schizophrenia.

      • Family Interventions

        • Family interventions should be part of the routine care for patients with schizophrenia.

        • Patients with schizophrenia whose families receive psychoeducation demonstrate reduced rates of hospitalization and show delayed or reduced symptomatic relapse.

        • Family psychoeducation programs should last more than 9 months and include features of engagement, support, and skills-building, not simply information- or knowledge-sharing.

    Service Delivery



    • Admission to acute care inpatient beds
      • Acute inpatient care is indicated for patients at high risk for suicide or assaultive behavior and for those with complex psychiatric and medical comorbidities. Randomized controlled studies of alternatives to inpatient care consistently demonstrate a need for inpatient care.

      • Services for patients presenting with a first episode of psychosis should be available on an urgent basis. Naturalistic studies demonstrate negative clinical outcomes prior to treatment; studies show correlations between duration of untreated psychosis and poor longer-term outcomes. Consistent application of evidenced-based care including pharmacotherapy, family therapy, and patient education yields superior outcomes.

      • Continuous care should be available in a comprehensive treatment program for up to 3 years following the first episode.

      • Specialized treatment services should be available for patients with a first episode of psychosis. Preliminary randomized controlled studies have provided some evidence of superior outcomes for specialized services, in addition to evidence from uncontrolled studies.

      • Assertive community treatment (ACT) programs should be available to selected patients who have a history of repeated admissions, are hard to engage in usual clinical settings or are homeless. Numerous randomized controlled trials have demonstrated some benefits from ACTs.

    • Case Management
      • Case management service should be available for those patients who have difficulty accessing the full range of services in the community.

      • Case management and ACTs can reduce the symptoms and the number and length of psychiatric hospitalizations.

    • Day Hospitals
      • Acute day hospital care is an Storiesalternative to full-time hospitalization for acute crises and as a step-up service for those who are doing poorly in outpatient care.

      • Day hospital admissions result in improved symptoms and treatment satisfaction; day hospitals cost less than inpatient care.


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    Monitoring Your Progress

    NOTE: When each of the following presentations finish; you must exit by manually closing its window in order to return to this webpage.

    The Healthy Social Behavior Scale lists social behaviors that research has found to be associated with healthy social relationships. You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.



    The Mental Health Scale lists behaviors and symptoms that research has found to be associated with mental health (or disorder). You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.



    The Life Satisfaction Scale lists the survey questions often used to measure overall satisfaction with life. You can keep score (totaling its 4-point scale answers) on a separate piece of paper to monitor your progress.



    Life Satisfaction Scale (5-Minute Video)

    The "Big 6" Dimensions of Mental Health

    Research has shown that there are 5 major dimensions (the "Big 5 Factors" or Five-Factor Model) of personality disorders and other mental disorders.

    This website uses these 5 major dimensions of human behavior (i.e., Agreeableness, Conscientiousness, Openness/Intellect, Extraversion/Sociability, and Emotional Stability) to describe all mental disorders. This website adds one more dimension, "Physical Health", to create the "Big 6" dimensions of mental health.

    The behaviors of the "Five Factor Model of Personality" represent five adaptive functions that are vital to human survival. For example, when one individual approaches another, the individual must: (1) decide whether the other individual is friend or foe [ "Agreeableness" ], (2) decide if this represents safety or danger [ "Emotional Stability" ], (3) decide whether to approach or avoid the other individual [ "Extraversion/Sociability" ], (4) decide whether to proceed in a cautious or impulsive manner [ "Conscientiousness" ], and (5) learn from this experience [ "Openness/Intellect" ].



    Desiderata (5-Minute Video)



    The following "Morning Meditation" allows you to plan your day using these "Big 6" dimensions of mental health.



    The following "Evening Meditation" allows you to review your progress on these "Big 6" dimensions of mental health.




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      "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

      Lord Kelvin (1824 – 1907)


    • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

    • Economist in grim battle against deceptive scholarship

    • List of Predatory Journals and Publishers

    • The power of asking "what if?"

    • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

    • Criteria For High Quality Research Studies

    • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

      • Randomized Controlled Trial:
        Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

      • Representative Sample:
        Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

      • Single Blind Trial:
        Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

      • Double Blind Trial (Better Than Single Blind Trial):
        Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

      • Baseline Comparability:
        Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

      • Confounding Factors:
        Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

      • Intervention Integrity:
        Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

      • Statistical analysis:
        Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

        Ask: Are the results both statistically significant and clinically significant? Many medical research findings are statistically significant (with a p-value <0.05), but they are not clinically significant because the difference between the experimental and control groups is too small to be clinically relevant.

        For example, the effect of a new drug may be found to be 2% better than placebo. Statistically (if the sample size was large enough) this 2% difference could be statistically significant (with a p-value <0.05). However, clinicians would say that this 2% difference is not clinically significant (i.e., that it was too small to really make any difference).

        Statistically, the best way to test for clinical significance is to test for effect size (i.e., the size of the difference between two groups rather than confounding this with statistical probability).

        When the outcome of interest is a dichotomous variable, the commonly used measures of effect size include the odds ratio (OR), the relative risk (RR), and the risk difference (RD).

        When the outcome is a continuous variable, then the effect size is commonly represented as either the mean difference (MD) or the standardised mean difference (SMD) .

        The MD is the difference in the means of the treatment group and the control group, while the SMD is the MD divided by the standard deviation (SD), derived from either or both of the groups. Depending on how this SD is calculated, the SMD has several versions such, as Cohen's d, Glass's Δ, and Hedges' g.

          Clinical Significance: With Standard Mean Difference, the general rule of thumb is that a score of 0 to 0.25 indicates small to no effect, 0.25-0.50 a mild benefit, 0.5-1 a moderate to large benefit, and above 1.0 a huge benefit. It is a convention that a SMD of 0.5 or larger is a standard threshold for clinically meaningful benefit.

        The statistical summary should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention).

        In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

          Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

          Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

          Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

        Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

      • Completeness of follow-up data:
        Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

      • Handling of missing data:
        Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

      • Replication of Findings:
        Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

      • Fraud:
        Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size ( n ), mean ( M ) and standard deviation ( SD ) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

        • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean ( M ) is defined as "the sum ( Sum ) of the values of each observation divided by the total number ( n ) of observations". So: M = Sum / n . Thus: ( Sum ) = ( M ) multiplied by ( n ). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate ( M ) multiplied by ( n ). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean ( M ) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value , and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

        • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible.

        • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

        • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

        • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

        • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

        • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

        • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

    • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

    • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

    • Not All Scientific Studies Are Created Equal - video

    • The efficacy of psychological, educational, and behavioral treatment

    • Estimating the reproducibility of psychological science

    • Psychologists grapple with validity of research

    • Industry sponsorship and research outcome (Review) - Cochrane Library

    • 'We've been deceived': Many clinical trial results are never published - (text and video)

    • Junk science misleading doctors and researchers

    • Junk science under spotlight after controversial firm buys Canadian journals

    • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

    • When Evidence Says No, But Doctors Say Yes


    • Cochrane Collaboration - the best evidence-based, standardized reviews available

    Research Topics

    Schizophrenia - Core Clinical Journals

    Schizophrenia - All Journals

    Schizophrenia - Review Articles - Core Clinical Journals

    Schizophrenia - Review Articles - All Journals

    Schizophrenia - Treatment - Core Clinical Journals

    Schizophrenia - Treatment - All Journals

    Click Here For Research Review Articles



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    Normal Distribution Of Human Attributes

    Regression to the Mean (Or Why Scientific Experiments Require A Control Group)

    The "Big 6" Dimensions of Mental Health

    Research has shown that there are 5 major dimensions (the "Big 5 Factors" or Five-Factor Model) of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Five Factor Model of Personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

    This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", to create the "Big 6" dimensions of mental health.)

    The behaviors of the "Five Factor Model of Personality" represent five adaptive functions that are vital to human survival. For example, when one individual approaches another, the individual must: (1) decide whether the other individual is friend or foe [ "Agreeableness" ], (2) decide if this represents safety or danger [ "Emotional Stability" ], (3) decide whether to approach or avoid the other individual [ "Extraversion/Sociability" ], (4) decide whether to proceed in a cautious or impulsive manner [ "Conscientiousness" ], and (5) learn from this experience [ "Openness/Intellect" ].

      Which "Big 6" Dimensions of Mental Health Are Impaired in Schizophrenia?

      THE POSITIVE SIDE OF THE "BIG 6" DIMENSIONS OF MENTAL HEALTH THE NEGATIVE SIDE OF THE "BIG 6" DIMENSIONS OF MENTAL HEALTH THIS DISORDER
      Agreeableness
      Being kind and honest.
      Antagonism
      Being unkind or dishonest.
      Conscientiousness
      Being diligent and self-disciplined.
      Disinhibition
      Being distractible, impulsive, or undisciplined.
      Openness/Intellect
      Showing good creativity, problem-solving, and learning ability
      Impaired Intellect
      Showing decreased creativity, problem-solving, or learning ability.
            Impaired Intellect and Psychosis
      Extraversion
      Being gregarious, assertive and enthusiastic.
      Detachment
      Being detached, unassertive, and unenthusiastic.
            Detachment
      Emotional Stability
      Being emotionally stable and calm.
      Emotional Distress
      Being emotionally unstable/distressed.
      Physical Health
      Being physically fit and healthy.
      Physical Symptoms
      Being physically unfit or ill.


      ( Note: On antipsychotic medication, many individuals with Schizophrenia can have a normal social life. However, their persisting cognitive impairments usually prevent them from having full-time employment.)





    The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder

    The problems that are characteristic of this disorder are highlighted with this pink background color.


    OPEN-MINDEDNESS VS. CLOSED-MINDEDNESS

    OPEN-MINDEDNESS (Intellect)
    Description: Intellect is synonymous with being open to experience and being intellectual. Openness to experience reflects appreciation for art, music, nature, beauty, adventure, and variety of experience. These individuals are willing to learn, be innovative, and be flexible. Intellect reflects one's cognitive capacity (e.g., reasoning, memory, attention, language and learning). Individuals with high Intellect are intellectually curious, quick to learn things, creative, formulate ideas clearly, and have a rich vocabulary. Humans are set apart from all other species by their intellectual curiosity and their need to tell stories as a form of social bonding. The Intellect dimension measures the behaviors that are central to the concept of WISDOM - having curiosity, experience, knowledge, and good judgment. (Science requires openness, intellectual curiosity, experimentation, and the free exchange of information.) High Intellect is associated with better: longevity, school and creative performance.
    Descriptors: Intelligent, good problem-solving, open-minded, open to new ideas, creative, innovative.
    • From Between facets and domains: 10 aspects of the Big Five
      • Intellectual:
        • Am quick to understand things
        • Can handle a lot of information
        • Like to solve complex problems
        • Have a rich vocabulary
        • Think quickly
        • Formulate ideas clearly
      • Open to Experience:
        • Original, come up with ideas
        • Value artistic, aesthetic experiences
        • Have an active imagination
        • Enjoy the beauty of nature
        • Believe in the importance of art
        • Love to reflect on things
        • Get deeply immersed in music
        • See beauty in things that others might not notice
        • Need a creative outlet
    • From International Personality Item Pool:
      • Like complex problems
      • Prefer variety to routine
      • Tend to vote for liberals
      • Have a vivid imagination
      • Believe in the importance of art
    Chimpanzees: Human babies vs. chimps: who's smarter? Chimps, orangutans, and human toddlers perform about equally well on "physical learning" (e.g., locating hidden objects, figuring out the source of a noise, understanding the concepts of more and less, using a stick to get something that's out of reach). Chimpanzees are far superior to humans in "working memory" (video) (i.e., the brain's ability to temporarily store and use information). Where human toddlers are far superior to these apes is on "social learning" tasks (e.g., understanding how to solve a problem by watching someone else do it, figuring out someone else's state of mind from their actions, or using nonverbal communication to explain or understand how to find something). Thus what makes human intelligence special is our ability to cooperate and communicate to share expertise. This has allowed us to build complex societies, collaborate and learn from each other at a high level, and use symbolic representation (writing, numerals, imagery) to communicate ideas.
    Evolution: The brains of intelligent species evolved the ability to detect correlational patterns in their perceptions. Then a few intelligent species evolved the ability to logically detect causal patterns in their perceptions (and later in their abstract or semantic information). [But will the human brain destroy itself?]
    Language Characteristics: Many positive emotion words (e.g. happy, good), high meaning elaboration, more perspective, politeness, few self-references, complex sentence constructions, few causation words, many inclusive words (e.g. with, and), few third person pronouns, many tentative words (e.g. maybe, guess), many insight words (e.g. think, see), few filler words and within-utterance pauses, stronger uncommon verbs.
    Research: Higher scores on Intellect are associated with greater creativity and general intelligence. *MRI research found that Intellect did not have any significant correlation with the volume of any localized brain structure. However cognitive testing has shown that "dorsolateral prefrontal cortex function as well as both fluid and crystalized cognitive ability was positively related to Intellect but no other personality trait."
    Relationship To General Intelligence: The "Big 5" personality dimension of Intellect appears to describe the individual's general intelligence (g). Research has shown that Intellect can be separated into 2 factors: Openness and Intellect. Intellect was independently associated with general intelligence (g) and with verbal and nonverbal intelligence about equally. Openness was independently associated only with verbal intelligence.
    Example: This video shows how we see what we want to see. What we pay attention to (or what we believe about the world) blinds us to reality. (Exit YouTube after first video.)
    Being Smart Is About Being Adaptive And Open To New Ideas: When facts prove them wrong, successful people are smart enough to admit that they are wrong and change their mind. Multi-billionaire Jeff Bezos said "that the smartest people are constantly revising their understanding, reconsidering a problem they thought they'd already solved." He said that people who are right a lot often change their minds a lot as well. According to Bezos, being truly smart is about being adaptive and open to new perspectives and ways of thinking. Bezos encourages people to "look for new ideas from everywhere."
    Our IQs Are Increasing: IQ gains have averaged 0.28 IQ points annually since 1908. That would mean that the average person in 1908 would be borderline retarded by today's standards. Likewise, the average person today would have a higher IQ that 98 percent of people in 1908. This could explain why modern moral judgments differ so dramatically from those of our Bronze Age ancestors. For example, the Bible condoned genocide (Deuteronomy 20:16–18, Joshua 10:40), slavery (Leviticus 25:44, Ephesians 6:5, 1 Timothy 6:1), and insisted on the death penalty for extramarital affairs (Deuteronomy 22:22) and for being a subborn and rebellious son (Deuteronomy 21:18-21).
    "I am original, and come up with new ideas."
    "I am curious about many different things."
    "I am quick to understand things."
    "I can handle a lot of information."
    "I like to solve complex problems."
    "I have a rich vocabulary."
    "I think quickly and formulate ideas clearly."
    "I Enjoy the beauty of nature"
    "I believe in the importance of art."
    "I love to reflect on things."
    "I get deeply immersed in music."
    "I see beauty in things that others might not notice."
    "I need a creative outlet."
    CLOSED-MINDEDNESS (Impaired Intellect)
    Description: Low Intellect is synonymous with being closed to experience and being unintellectual. Individuals that are closed to experience are rather unimpressed by most works of art, prefer routine over variety, stick to what they know, and prefer less abstract arts and entertainment. Individuals with low intellect are not intellectually curious, learn things slowly, have difficulty understanding abstract ideas, avoid creative pursuits, and feel little attraction toward ideas that may seem radical or unconventional.
    Descriptors: Unwise, poor problem-solving, closed-minded, not open to new ideas, uncreative, not innovative.
    • From Between facets and domains: 10 aspects of the Big Five
      • Unintellectual:
        • Have difficulty understanding abstract ideas
        • Avoid philosophical discussions
        • Avoid difficult reading material
        • Learn things slowly
      • Closed to Experience:
        • Do not like poetry
        • Seldom get lost in thought
        • Seldom daydream
        • Seldom notice the emotional aspects of paintings and pictures
    • From International Personality Item Pool:
      • Avoid philosophical discussions
      • Dislike changes
      • Believe in one true religion
      • Seldom daydream
      • Do not like poetry
    How The Military Exploited The Intellectually Impaired: It can be fatal when others deny that an individual is intellectually impaired. This often happens in the military.
    Language Characteristics:
    Few positive emotion words, low meaning elaboration, less perspective, less politeness, few positive emotion words, many self-references, simple sentence construction, many causation words (e.g. because, hence), many third person pronouns, few tentative words, few insight words, many filler words and within-utterance pauses, milder verbs.
    "I prefer work that is routine."
    "I have difficulty understanding abstract ideas."
    "I think slowly."
    "People find it hard to follow my logic or understand my thoughts."
    "I avoid philosophical discussions."
    "I avoid difficult reading material."
    "People find it hard to follow my logic or understand my thoughts."
    "I have few artistic interests."
    "I seldom notice the emotional aspects of paintings and pictures."
    "I do not like poetry."
    "I seldom get lost in thought."
    "I seldom daydream."
    Cognitive Impairment
    * Distractibility:
    "I can't focus on things for very long."
    "I am easily distracted."
    "I have trouble pursuing specific goals even for short periods of time."
    "I can't achieve goals because other things capture my attention."
    "I often make mistakes because I don't pay close attention."
    "I waste my time ."
    "I find it difficult to get down to work."
    "I mess things up."
    "I don't put my mind on the task at hand."
    * Memory Impairment: [When Severely Ill]
    "I have difficulty learning new things, or remembering things that happened a few days ago."
    "I often forget a conversation I had the day before."
    "I often forget to take my medications, or to keep my appointments."
    * Impaired Reasoning:
    "My judgment or ability to solve problems isn't good."
    "I have difficulty understanding abstract ideas."
    "I think slowly."
    "People find it hard to follow my logic or understand my thoughts."
    Psychoticism
    Description: Psychoticism is the state of being psychotic or of being predisposed to develop psychosis.
    Descriptors: Unusual beliefs and experiences, eccentricity, perceptual dysregulation.
    Screening Questions:
    • "My thoughts often don’t make sense to others."
    • "I have seen things that weren’t really there."
    • "I often have thoughts that make sense to me but that other people say are strange."
    • "I often “zone out” and then suddenly come to and realize that a lot of time has passed."
    • "Things around me often feel unreal, or more real than usual."
    * Eccentricity (Disorganized Speech or Behavior):
    "I often have thoughts that make sense to me but that other people say are strange."
    "Others seem to think I'm quite odd or unusual."
    "My thoughts are strange and unpredictable."
    "My thoughts often don’t make sense to others."
    "Other people seem to think my behavior is weird."
    "I have several habits that others find eccentric or strange."
    "My thoughts often go off in odd or unusual directions."
    * Unusual Beliefs and Experiences:
    "I often have unusual experiences, such as sensing the presence of someone who isn't actually there."
    "I've had some really weird experiences that are very difficult to explain."
    "I have seen things that weren’t really there."
    "I have some unusual abilities, like sometimes knowing exactly what someone is thinking."
    "I sometimes have heard things that others couldn’t hear."
    "Sometimes I can influence other people just by sending my thoughts to them."
    "I often see unusual connections between things that most people miss."
    * Perceptual Dysregulation:
    "Things around me often feel unreal, or more real than usual."
    "Sometimes I get this weird feeling that parts of my body feel like they're dead or not really me."
    "It's weird, but sometimes ordinary objects seem to be a different shape than usual."
    "Sometimes I feel 'controlled' by thoughts that belong to someone else."
    "Sometimes I think someone else is removing thoughts from my head."
    "I have periods in which I feel disconnected from the world or from myself."
    "I can have trouble telling the difference between dreams and waking life."
    "I often 'zone out' and then suddenly come to and realize that a lot of time has passed."
    "Sometimes when I look at a familiar object, it's somehow like I'm seeing it for the first time."
    "People often talk about me doing things I don't remember at all."
    "I often can't control what I think about."
    "I often see vivid dream-like images when I’m falling asleep or waking up."
    ("OPENNESS TO EXPERIENCE vs. BEING CLOSED TO EXPERIENCE" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five) [More Information]
    *MRI Research:
    Testing predictions from personality neuroscience. Brain structure and the big five.


    EXTRAVERSION VS. DETACHMENT

    EXTRAVERSION (Sociality)
    Description: Extraversion is synonymous with being outgoing, gregarious, enthusiastic and assertive. Assertiveness encompasses traits relating to leadership, dominance, and drive. Enthusiasm encompasses both sociability and the tendency to experience and express positive emotion. Individuals with high Extraversion feel positively about themselves, feel confident when leading or addressing groups of people, enjoy social gatherings and interactions, and experience positive feelings of enthusiasm and energy. The Extraversion dimension measures the behaviors that are central to the concept of SOCIALITY - the tendency to associate in or form social groups. High Extraversion is associated with better: longevity, leadership, job [sales] performance. (This dimension appears to measure the behaviors that differentiate approach from avoidance.)
    Descriptors: Sociable, talkative, enthusiastic, energetic, assertive, self-confident.
    • From Between facets and domains: 10 aspects of the Big Five
      • Enthusiasm:
        • Talkative
        • Sociable, outgoing
        • Make friends easily
        • Warm up quickly to others
        • Show my feelings when I’m happy
        • Have a lot of fun
        • Laugh a lot
      • Assertiveness:
        • Take charge
        • Have a strong personality
        • Know how to captivate people
        • See myself as a good leader
        • Can talk others into doing things
        • Am the first to act
    • From International Personality Item Pool:
      • Love large parties
      • Make friends easily
      • Am always busy
      • Love excitement
      • Take charge
    Evolution: Humans have always depended on social cooperation for their survival. Our earliest caveman ancestors were too physically weak to survive without the help of their social group. Research has shown that our brains can't remain sane without social and/or environmental stimulation. A person undergoing mild sensory and total social deprivation in a room for 3-4 days will become confused and start to lose contact with reality. To remain sane, our brains must be connected to a social network. The relative social and sensory deprivation of astronauts in space may become a major problem. Martin Seligman (in his book "Flourish" p.147) states:

      "One American astronaut almost aborted an entire earth orbit mission by shutting off communications for several orbits, out of pique that his music player had not yet been repaired in spite of his repeated requests."

    The brains of animal social species evolved an opioid neurotransmitter system that produces positive emotion which is important for social affiliation. These species also evolved a dopamine neurotransmitter system that produces drive and heightened approach behavior.
    Language Characteristics: Many topics, higher verbal output, think out loud, pleasure talk, agreement, compliment, positive emotion words, sympathetic, concerned about hearer, simple constructions, few unfilled pauses, few negations, few tentative words, informal language, exaggeration, many words related to humans (e.g. "man", "pal"), poor vocabulary.
    Research: Higher scores on Extraversion are associated with greater happiness and broader social connections. *MRI research found that Extraversion was associated with increased volume of medial orbitofrontal cortex, a region involved in processing reward information.
    Video Example: Here is an example of a delightful extraverted, sociable couple proudly showing their catamaran sailboat which they are sailing around the world.
    "I'm talkative"
    "I'm not reserved."
    "I'm full of energy."
    "I generate a lot of enthusiasm."
    "I'm not quiet."
    "I have an assertive personality."
    "I'm not shy or inhibited."
    "I am outgoing and sociable."
    "I make friends easily."
    "I warm up quickly to others."
    "I show my feelings when I'm happy."
    "I have a lot of fun."
    "I laugh a lot."
    "I take charge."
    "I have a strong personality."
    "I know how to captivate people."
    "I see myself as a good leader."
    "I can talk others into doing things."
    "I am the first to act."
    DETACHMENT (Impaired Sociality)
    Description: Detachment is synonymous with low enthusiasm and low assertiveness. Individuals with high Detachment consider themselves unpopular, feel awkward when they are the center of social attention, are indifferent to social activities, and feel less lively and optimistic than others do.
    ICD-11 Description: The core feature of the Detachment trait domain is the tendency to maintain social detachment (interpersonal distance) and emotional detachment (emotional distance). Common manifestations of Detachment include: social detachment (avoidance of social interactions, lack of friendships, and avoidance of intimacy); and emotional detachment (reserve, aloofness, and limited emotional expression and experience).
    Descriptors: Withdrawn, quiet, unenthusiastic, apathetic, unassertive, shy.
    • From Between facets and domains: 10 aspects of the Big Five
      • Unenthusiastic:
        • Reserved
          Rarely get caught up in the excitement
          Am not a very enthusiastic person
          Am hard to get to know
          Keep others at a distance
          Reveal little about myself
      • Unassertive:
        • Do not have an assertive personality
          Lack the talent for influencing people
          Wait for others to lead the way
          Hold back my opinions.
    • From International Personality Item Pool:
      • Prefer to be alone
      • Am hard to get to know
      • Like to take it easy
      • Dislike loud music
      • Wait for others to lead the way
    Language Characteristics: Single topic, doesn't think out loud, problem talk, dissatisfaction, emotional distress words, not sympathetic, elaborated sentence constructions, many unfilled pauses, formal language, many negations, many tentative words (e.g. maybe, guess), few swear words, little exaggeration, few words related to humans, rich vocabulary.
    Screening Questions:
    • "I often feel down, depressed, or hopeless."
    • "I steer clear of romantic relationships."
    • "I’m not interested in making friends."
    • "I don’t like to get too close to people."
    • "I rarely get enthusiastic about anything."
    * Social Withdrawal:
    "I don’t like to get too close to people."
    "I don't deal with people unless I have to."
    "I'm not interested in making friends."
    "I don’t like spending time with others."
    "I say as little as possible when dealing with people."
    "I keep to myself."
    "I am hard to get to know."
    "I reveal little about myself."
    "I do not have an assertive personality."
    "I lack the talent for influencing people."
    "I wait for others to lead the way."
    "I hold back my opinions."
    * Intimacy Avoidance:
    "I steer clear of romantic relationships."
    "I prefer to keep romance out of my life."
    "I prefer being alone to having a close romantic partner."
    "I'm just not very interested in having sexual relationships."
    "II break off relationships if they start to get close."
    * Loss of Interest or Pleasure:
    "I often feel like nothing I do really matters."
    "I almost never enjoy life."
    "Nothing seems to make me feel good."
    "Nothing seems to interest me very much."
    "I almost never feel happy about my day-to-day activities."
    "I rarely get enthusiastic about anything."
    "I don't get as much pleasure out of things as others seem to."
    * Restricted Emotions:
    "I don't show emotions strongly."
    "I don't get emotional."
    "I never show emotions to others."
    "I don't have very long-lasting emotional reactions to things."
    "People tell me it's difficult to know what I'm feeling."
    "I am not a very enthusiastic person."
    ("Extraversion vs. Detachment" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five) [More Information]
    *MRI Research:
    Testing predictions from personality neuroscience. Brain structure and the big five.



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