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.
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:
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.
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.
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.
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.
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.
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)
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.
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.
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.
Brain on Fire" (netflix movie) - A true story of a woman
misdiagnosed as having Bipolar Disorder or Schizophrenia - despire having seizures,
catatonia and marked neurological deficits. The end of the story is heart-warming.
In Mental Health Adventures Robert Winram recalls his decades
of working with Dr. Phil Long to develop innovative social activities and a mutual
support network for Dr. Long's patients. The creative partnership between Robert (a
mental health advocate) and Dr. Long (a psychiatrist) hopefully will stand as an
example for others to follow.
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
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."
(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?)
(Editor: It now is essential that clinicians follow these guidelines to
metabolically monitor their patients on obesity-inducing antipsychotic medications.)
(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.)
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.
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).
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.)"
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.
$2.7 Billion Fines For Antipsychotic Medication
Manufacturers
- Pharmaceutical companies have paid prosecutors $2.7 billion in
settlements over their illegal off-label marketing of their antipsychotics. These
are the largest criminal fines ever paid by pharmaceutical companies.
Brain Games Are Bogus - Brain training has become a
multi-million-dollar business, yet recent research has found that this training
isn't doing anyone much good.
Life in Prison
Documentary 2017: US Prisons Are Hell On Earth - USA has 5% of the world's
population and 25% of the world's prison inmates. The US prison system has almost no
rehabilitation focus, and eventually releases prisoners in worse criminal shape than
when they entered prison. There are more severely mentally ill in US prisons than
there are in US mental hospitals. Thus gross underfunding of US mental health
programs has resulted in prisons becoming the new locked asylums that replace US
mental hospitals.
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.
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"
].
"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!
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.
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.)
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!
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.
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.
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."
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.
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.
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.
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."