What is Schizophrenia

  

Compiled by Ruwan M Jayatunge M.D. 

Special Thanks to Dr Peter Zelina Psychiatrist at the Mackenzie Health

Schizophrenia is a chronic, often episodic and challenging complex biochemical brain disorder. The illness affects how a person thinks, feels, behaves and relates to others. The illness occurs in both men and women, but it is slightly more common in men. People with schizophrenia are affected by delusions (fixed false beliefs that can be terrifying to the person experiencing them), hallucinations (sensory experiences, such as hearing voices talking about them when there is no one there), social withdrawal and disturbed thinking.

The evolution of the concept of schizophrenia dates back to the 1850s when Kraepelin delineated symptomatology which shared a common course and outcome and called it as dementia precox. Later, Bleuler coined the term “schizophrenia” describing it as a group of psychosis having a variable and chronic course. It was Bleuler in 1911, who first gave the concept that changes in a person who develops schizophrenia can be identified as a prodromal phase.

Schizophrenia often starts so gradually that people experiencing symptoms and their families may not be aware of the illness for a long time. For some, however, the symptoms come on rapidly and are more easily recognized. Schizophrenia has three phases: prodromal (or beginning), active and residual. These phases tend to occur in sequence and to repeat in cycles throughout the illness. The length of each phase varies from person to person.

Abnormalities in neurotransmission have provided the basis for theories on the pathophysiology of schizophrenia. Abnormal activity at dopamine receptor sites (specifically D₂) is thought to be associated with many of the symptoms of schizophrenia. Schizophrenia could be the consequence of a problem in communication between neurons. It has been observed that dopamine undergoes the greatest alteration of all the neurotransmitters. Motivation, cognition, memory, executive functioning, affect, and social communication are all altered in schizophrenia.

Almost half of all patients with schizophrenia present alterations in brain structure. These include ventricular dilation, a decrease in the volume of certain areas of the brain (especially the temporal lobe, amygdala-hippocampal formation, thalamus, prefrontal cortex) and an overall decrease in brain size.

The lifetime risk of developing schizophrenia is widely accepted to be around 1 in 100. When treated properly, many people with schizophrenia are able to enjoy fulfilling, productive lives.

Risk Factors

Researchers believe that a number of genetic and environmental factors contribute to causation, and life stressors may play a role in the disorder’s onset and course. Since multiple factors may contribute, scientists cannot yet be specific about the exact cause in individual cases. Since the term schizophrenia embraces several different disorders, variation in cause between cases is expected.

• The risk is higher when a close family member has the illness.
• Schizophrenia may be influenced by brain development factors before and around the time of birth, and during childhood and adolescence.
• People who have experienced social hardship or trauma, particularly during childhood, have a higher risk.
• Cannabis use increases the risk of developing schizophrenia in youth and of triggering an earlier onset of the illness in people who are genetically vulnerable.
• Being born or spending one’s childhood in an urban environment, rather than a rural one, increases the risk.
• Particular immigrant and refugee groups in Ontario may have a higher risk of developing psychotic disorders such as schizophrenia.

Causes

The exact cause of schizophrenia is unknown. Medical researchers believe several factors can contribute.  Research suggests that schizophrenia may have several possible causes:

 • Genetics. Schizophrenia isn’t caused by just one genetic variation, but a complex interplay of genetics and environmental influences. While schizophrenia occurs in 1% of the general population, having a history of family psychosis greatly increases the risk. Schizophrenia occurs at roughly 10% of people who have a first-degree relative with the disorder, such as a parent or sibling.

• Environment. Exposure to viruses or malnutrition before birth, particularly in the first and second trimesters has been shown to increase the risk of schizophrenia. Inflammation or autoimmune diseases can also lead to increased immune system

• Brain chemistry. Problems with certain brain chemicals, including neurotransmitters called dopamine and glutamate, may contribute to schizophrenia. Neurotransmitters allow brain cells to communicate with each other. Networks of neurons are likely involved as well.

• Drug use. Some studies have suggested that taking mind-altering drugs during teen years and young adulthood can increase the risk of schizophrenia. A growing body of evidence indicates that smoking marijuana increases the risk of psychotic incidents and the risk of ongoing psychotic experiences. The younger and more frequent the use, the greater the risk.

Another study has found that smoking marijuana led to earlier onset Researchers still don't know exactly what causes schizophrenia, but they do know that the brains of people living with schizophrenia are different, as a group, from the brains of those who don't live with the illness.  Research strongly suggests that schizophrenia has something to do with problems involving brain chemistry and brain structure and, like many other medical illnesses, is thought to be caused by a combination of problems, some inherited and others occurring during a person's development. For example, some researchers think that schizophrenia may be triggered by a viral infection affecting the brain very early in life or by mild brain damage from complications during birth. Drug use can trigger underlying genetic vulnerability in a person. Another study has found that smoking marijuana led to earlier onset of schizophrenia and often preceded the manifestation of the illness.

It is still premature to label schizophrenia as either a neurodevelopmental (impairment of the growth and development of the brain) or a neurodegenerative (progressive loss of structure or function of neurons) disorder, as both seem to be in play over the course of the illness.

Scientists are working to understand if changes in the brain are present early in life and how much those changes worsen over time.  People can develop schizophrenia at any age. About 1 percent of the world's population develops schizophrenia, meaning that out of all the people born today, one in 100 will develop the disorder by the time they reach age 55. About 75 percent of people living with the illness develop it between the ages of 16- 40; women typically have a later onset than men. Children can also be diagnosed with schizophrenia, though this is quite rare before the age of 12. New cases are uncommon after age 40.

Early warning signs of Schizophrenia

In some people, schizophrenia appears suddenly and without warning. But for most, it comes on slowly, with subtle warning signs and a gradual decline in functioning long before the first severe episode.

Psychosis is characterized as disruptions to a person’s thoughts and perceptions that make it difficult for them to recognize what is real and what isn’t. Early or first-episode psychosis (FEP) refers to when a person first shows signs of beginning to lose contact with reality. During early psychosis or a first episode is the most important time to connect with the right treatment. Doing so can be life-changing and radically alter a person’s future. 

The most common early warning signs of schizophrenia include:

1. Depression, social withdrawal
2. Hostility or suspiciousness, extreme reaction to criticism
3. Deterioration of personal hygiene
4. Flat, expressionless gaze
5. Inability to cry or express joy or inappropriate laughter or crying
6. Oversleeping or insomnia; forgetful, unable to concentrate
7. Odd or irrational statements; strange use of words or way of speaking

Prodromal Phase of Schizophrenia (“schizophrenia prodrome”)

Prodrome in clinical medicine refers to the early symptoms and signs of illness preceding the characteristic manifestations. About 75% of people with schizophrenia go through a prodrome phase. It may last a few weeks, but for some people, these signs slowly worsen over several years. When symptoms develop gradually, people may begin to lose interest in their regular activities and withdraw from friends and family members. They may become confused; have trouble concentrating and feel listless and apathetic, preferring to spend most of their days alone. They may also become intensely preoccupied with certain topics or ideas (e.g., persecution, religion, public figures). Family and friends may be upset with this behaviour, not understanding that it is caused by illness. Occasionally, these symptoms reach a plateau and do not develop further but, in most cases, an active phase of the illness follows. The prodromal period can last weeks, months or even years.

Symptoms of Schizophrenia

Schizophrenia includes “positive” and “negative” symptoms of psychosis, as well as cognitive symptoms.  Positive symptoms are those that add to or distort the person’s normal functioning. Negative symptoms involve normal functioning becoming lost or reduced. Negative Symptoms are the inability to initiate and persist in goal-directed activities or diminished emotional expressiveness. Cognitive symptoms include difficulties with attention, concentration and memory. There are five types of symptoms characteristic of schizophrenia: delusions, hallucinations, disorganized speech, disorganized behavior, and the so-called “negative” symptoms.

a)      Positive psychotic symptoms: Hallucinations, such as hearing voices, paranoid delusions and exaggerated or distorted perceptions, beliefs and behaviors.

b)      Negative symptoms: A loss or a decrease in the ability to initiate plans, speak, express emotion or find pleasure

c)      Disorganization symptoms: Confused and disordered thinking and speech, trouble with logical thinking and sometimes bizarre behavior or abnormal movements.

d)     Impaired cognition: Problems with attention, concentration, memory and declining educational performance.

Types of Delusions  - Persecutory  - Referential  - Guilt  - Religious  - Nihilism  - Somatic  - Bizarre  Hallucinations  - Auditory  - Visual  - Somatic  - Olfactory  Thought disorder

Cognitive deficits including memory, attention, and concentration are the most commonly documented clinical findings in Schizophrenia. This may incorporate relative disturbance in speed and verbal memory, social reasoning, and emotional processing. Various mood changes such as anxiety, depression, mood swings, sleep disturbances, irritability, anger, and suicidal ideas are reported as part of prodromal symptoms. Patient may also present with spectrum of conditions including obsessive-compulsive phenomenon and dissociative disorders. 

Stages of schizophrenia

The medical and research communities have agreed that there are three distinct phases people go through when they have schizophrenia:

Phase 1: Acute -This is when major symptoms make it clear that the individual needs medical help. It may come on very gradually or quite suddenly.

Phase 2: Stabilization -This is the time when the illness is out of the acute stage and symptoms are reduced.

Phase 3: Stable or chronic- The acute symptoms are being managed but there may still be difficulty  with ability to function and periodic relapses into Phase 1 and 2

                                                      

Social Withdrawal in Schizophrenia

One of the earliest symptoms that many people with schizophrenia experience is a change in their sensitivity toward others. A person may become more sensitive to and aware of other people, or they may withdraw and pay little or no attention to others. The person may become suspicious and worried that others are avoiding them, talking about them or feeling negatively toward them. The person may feel safer and calmer being alone. They may also become so absorbed in their own thoughts and sensations that they lose interest in the feelings and lives of others. They may spend more time alone in their room, not engaging with family or friends.

Reduced emotional expression

Many people with schizophrenia tend to have reduced emotional expressiveness. This may be seen in a lack of facial expression, a monotonous voice, fixed or prolonged staring, and less expressive body language than before the illness began.

Reduced Motivation

A person with schizophrenia may have problems finishing tasks or making and carrying out plans. They may also have less energy and drive, both before and after an active phase of the illness. Some people misinterpret this behaviour as laziness or as “not wanting to try.” They may believe the behaviour is intentional, and become frustrated with the person. But this behaviour is related to the illness and not to the person’s character.

Ambivalence

Ambivalence means having conflicting ideas, wishes and feelings toward a person, thing or situation. A person with schizophrenia may feel uncertainty and doubt. It may be hard for them to make up their mind about anything, even common decisions such as what to wear in the morning. Often, even when they are able to make a decision, they find it hard to stick with it.

Lack of insight

People with schizophrenia may not consider what they are experiencing to be an illness. This lack of insight or awareness may be present throughout the illness, and can contribute to a decision to reject a recommended treatment plan. Family members may find this particularly difficult to understand and accept.

Schizophrenia Types

Schizophrenia was once divided into five subtypes.  In 2013, the subtypes were eliminated. Today, schizophrenia is one diagnosis.

The names of the individual types help doctors and healthcare providers plan treatments. However, they no longer are used as a clinical diagnosis.

These types included:

• Paranoid. Paranoid-type schizophrenia is distinguished by paranoid behavior, including delusions and auditory hallucinations. Paranoid behavior is exhibited by feelings of persecution, of being watched, or sometimes this behavior is associated with a famous or noteworthy person a celebrity or politician, or an entity such as a corporation. People with paranoid-type schizophrenia may display anger, anxiety, and hostility. The person usually has relatively normal intellectual functioning and expression of affect. In 2013, doctors decided that paranoia is a “positive” symptom of the disorder, not a separate type.

• Hebephrenic or disorganized. This type was diagnosed in people who didn’t experience hallucinations or delusions but did have disorganized speech or behaviors. A person with disorganized-type schizophrenia will exhibit behaviors that are disorganized or speech that may be bizarre or difficult to understand. They may display inappropriate emotions or reactions that do not relate to the situation at-hand. Daily activities such as hygiene, eating, and working may be disrupted or neglected by their disorganized thought patterns.

• Undifferentiated. Doctors diagnosed people with this subtype who showed more than one type of predominant symptom. Undifferentiated-type schizophrenia is a classification used when a person exhibits behaviors which fit into two or more of the other types of schizophrenia, including symptoms such as delusions, hallucinations, disorganized speech or behavior, catatonic behavior.

• Residual. If someone was diagnosed with schizophrenia early in their life but didn’t show symptoms later, this subtype might have been used for them. When a person has a past history of at least one episode of schizophrenia, but the currently has no symptoms (delusions, hallucinations, disorganized speech or behavior) they are considered to have residual-type schizophrenia. The person may be in complete remission, or may at some point resume symptoms.

• Catatonic. As the name suggests, this sub type  was diagnosed in people who showed signs of mutism or who developed a stupor-like affect. Disturbances of movement mark catatonic-type schizophrenia. People with this type of schizophrenia may vary between extremes: they may remain immobile or may move all over the place. They may say nothing for hours, or they may repeat everything you say or do. These behaviors put these people with catatonic-type schizophrenia at high risk because they are often unable to take care of themselves or complete daily activities.

Diagnosing Schizophrenia

There is no single laboratory or brain imaging test for schizophrenia. Schizophrenia treatment professionals must rule out multiple factors such as brain tumors and other medical conditions (as well as other psychiatric diagnoses such as bipolar disorder). At the same time, they must identify different kinds of symptoms that manifest in specific ways over certain periods of time. To make matters more complicated, the person in need of mental health help and treatment may be in such distress that they have a hard time communicating. It often takes a decade for people to be properly diagnosed with schizophrenia.

A diagnosis of schizophrenia is based on:

• the information gathered
• ruling out other possible explanations
• the physician or psychologist’s clinical judgment
• certain symptoms, described above, that have been present for at least one month and last for at least six months
• symptoms that are severe enough to have an impact on the person’s social, educational or occupational functioning and abilities.

Differential Diagnosis 

Some of the disorders related to schizophrenia (or with similar symptoms) are:

·       schizophreniform disorder

·       bipolar disorder

·       depression with psychosis

·       schizotypal personality disorder

·       substance-induced psychosis

·       brief psychotic disorder

·       schizoaffective disorder

·       delusional disorder

Brain Imaging Studies and Schizophrenia

Historically, Kraepelin speculated that dementia praecox resulted from damage to the cerebral cortex, most notably the frontal and temporal cortices. Schizophrenia, once considered a psychological malady devoid of any organic brain substrate, has been the focus of intense neuroimaging research. In patients with schizophrenia neuroimaging studies have revealed global differences with some brain regions showing focal abnormalities. White matter abnormalities have been reported to be widespread in schizophrenia.

The majority of functional neuroimaging studies, which study not just the structure but also brain function, have observed that individuals with schizophrenia present a decrease in prefrontal cortex function. Neuroimaging studies of schizophrenia have identified abnormalities in neuroanatomy, regional brain metabolism and receptor physiology. Computerized tomographic (CT) studies have demonstrated gross ventricular and sulcal enlargement.

Neuroimaging investigations in schizophrenia have produced a large body of evidence for structural connectivity abnormalities associated with the illness. The underlying neural substrates of schizophrenia likely involve alterations of brain circuitry. The structural circuits of cortical and subcortical areas serve normal brain functions, disrupted communication within and between brain regions may be the core pathology of schizophrenia. Widespread alterations in connectivity are present in the brains of chronic and first episode schizophrenia patients and there is some evidence that patterns of reduced connectivity cut across the different stages of the disorder, including those with an increased risk of developing the illness. 

First demonstrated brain abnormalities on CT scans in patients with schizophrenia indicates enlarged ventricles is still the most consistent and reproducible finding in neuroimaging studies of schizophrenia (McCarley et al 1999). Hippocampal dysfunctions and l volume deficits have been reported in chronically-treated schizophrenia patients.

Schizophrenia and Substance Abuse

Substance abuse is very common among people with schizophrenia. And, for many people, multiple substances are abused including alcohol, tobacco, marijuana, amphetamines (speed) and other drugs. Over-the-counter drugs such as antihistamines and pain killers can also be abused. Up to 80% of people with schizophrenia are smokers. Unfortunately, many people who abuse substances aren’t considering changing their substance use lifestyle. Again, the support of family and peer support can be very helpful.

Schizophrenia and Risk of Violence

A common myth about people with schizophrenia is that they are violent. In fact, people with schizophrenia are more often the victims of violent crime than they are the perpetrators. Homelessness, substance use and severe symptoms increase the risk that a person with schizophrenia will be victimized. Aggression and hostility can be associated with schizophrenia, though spontaneous or random assault by a person with schizophrenia is rare. It is not possible to predict with certainty who may be violent. Most people with schizophrenia are not violent. If a person has symptoms of schizophrenia, it is important to help him or her get treatment as quickly as possible. The risk of violence is greatest when schizophrenia is untreated since the illness may get worse over time. People with schizophrenia are much more likely than those without the illness, to be harmed by others as well as harm themselves.

Schizophrenia and Suicidal Risk

People with schizophrenia are six times more likely to attempt suicide than the general population. However, this does not mean that a diagnosis of schizophrenia will lead to suicidal behaviour or death by suicide. Patients with chronic schizophrenia may have a higher prevalence of lifetime suicide attempts than the general population. In addition gray matter deficits have been consistently revealed in chronic treated schizophrenia. Depression is a common symptom in people who are developing schizophrenia and those who are living with it. The loss of hopes and dreams combined with inadequate recovery leads to between 4 and 6 in 10 people with schizophrenia attempting suicide. Some people may also have a hallucination that tells them to attempt suicide. Between 5 and 10% of people with schizophrenia die by suicide. Although schizophrenia is not in itself a fatal disease, death rates of people with schizophrenia are at least twice as high as those in the general population. The excess mortality has been related in the past to poor conditions of prolonged institutional care, leading to high occurrence of tuberculosis and other communicable diseases (Allebeck, 1989). Suicide, particularly, has emerged as a growing matter of concern, since lifetime risk of suicide in schizophrenic disorders has been estimated at above 10%, which is about 12 times that of the general population (Caldwell and Gottesman, 1990). There seems to be an increased mortality for cardiovascular disorders as well (Allebeck, 1989), possibly related to unhealthy lifestyle.

Schizophrenia and Co-occurring Disorders

In recent years, a number studies of diagnostic patterns in both clinical and community samples have shown that comorbidity among mental disorders is fairly common (Kessler, 1995). Schizophrenia is no exception: the risk in people with schizophrenia of meeting criteria for other mental disorders is many times higher than in the general population. In relation to treatment and prognostic issues, comorbidity with depression and substance abuse is especially relevant.

When someone is living with schizophrenia and another medical or psychiatric condition (known as a co-occurring disorder), it is important that all aspects of care are coordinated, especially medications. It is not uncommon for people living with schizophrenia to experience depression, although it may be difficult to distinguish depression (low mood) from the negative symptoms that affect someone's ability to display emotion. Symptoms of depression in addition to the existing symptoms of schizophrenia may significantly add to a person's distress and increase the likelihood of suicide. It is important to discuss any possible symptoms of depression with a health professional and examine antidepressants, such as Selective Serotonin Reuptake Inhibitors (SSRIs) that may be safely added to the current schizophrenia treatment. 

About 25 percent of people living with schizophrenia also have a substance abuse disorder, frequently called a dual diagnosis. While it may seem like a way to escape from the distressing experiences associated with the illness, substance abuse can make schizophrenia treatment less effective or make people in need of mental health help less likely to follow their treatment plan. Drugs like marijuana and stimulants such as amphetamines or cocaine may make symptoms worse. Marijuana use, in particular, is thought to have a correlation with the onset of schizophrenia, perhaps triggering the illness in those with a genetic predisposition. Traditional 12- step programs, such as Narcotics Anonymous and Alcoholics Anonymous, can be effective for some people living with schizophrenia, while others do better with treatment specialized for the needs of individuals living with a dual-diagnosis.

Treatment

Schizophrenia is a psychiatric disorder which involves psychotic symptoms such as distortions in thought and perception, blunted affect, and behavioural disturbances. It is important for patients who have a first episode of psychosis to be correctly diagnosed as soon as possible. The earlier schizophrenia is diagnosed the better the treatment outcome. The benefits of early intervention in schizophrenia to patients include prevention of neurobiological changes, minimization of secondary morbidity and prevention of relapse.

Treatment planning has three goals:

1) reduce or eliminate symptoms,

 2) maximize quality of life and adaptive functioning,

 3) promote and maintain recovery from the debilitating effects of illness to the maximum extent possible

Schizophrenia treatment requires an all-encompassing approach, and it is important to develop a plan of care that is tailored to each person's needs. Mental health care providers and the individual needing mental health help should work together to craft this plan. Treatment can help many people with schizophrenia lead highly productive and rewarding lives. As with other chronic illnesses, some patients do extremely well while others continue to be symptomatic and need support and assistance.

Psychosis is believed to be caused in part by overactivity of a brain chemical called dopamine. Antipsychotics work by blocking this dopamine effect. This helps to relieve the positive symptoms of psychosis, but it does not always make them go away completely. A person may still hear voices and have delusions, but they are more able to recognize what isn’t real and to focus on other things, such as work, school or family.

• Medication is often the first treatment for schizophrenia. The main medications used to treat symptoms of schizophrenia are antipsychotics. They may be used in combination with medications for other mental health symptoms, such as mood stabilizers, sedatives and antidepressants, and medications to help with the side-effects of antipsychotics.
• Brain stimulation therapies may also sometimes be used. They include electroconvulsive therapy and transcranial magnetic stimulation.
• Psychosocial therapies and supports help people to develop recovery skills, such as setting and achieving goals. They include psychoeducation, cognitive-behavioural therapy, cognitive adaptation training, concurrent disorders treatment and family therapy and supports.

Other forms of treatment for schizophrenia include peer support, medical care, physical activity, diet and complementary approaches.

After the symptoms of schizophrenia are controlled, various types of therapy can continue to help people manage the illness and improve their lives. Therapy and supports can help people learn social skills, cope with stress, identify early warning signs of relapse and prolong periods of remission. Because schizophrenia typically strikes in early adulthood, individuals with the disorder often benefit from rehabilitation to help develop life-management skills, complete vocational or educational training, and hold a job. For example, supported-employment programs have been found to help persons with schizophrenia obtain self-sufficiency. These programs provide people with severe mental illness with competitive jobs in the community.

Antipsychotic medications Specialists in schizophrenia describe antipsychotic medications as being either first-generation or second-generation. Second-generation medications provide effective symptom relief and have fewer side effects than first-generation medications. The medication treatment for people with schizophrenia is unique to each person. It will depend on a number of factors including severity of symptoms, overall health, presence of other conditions, etc. Finding the right balance of medications – whether they are first- or second-generation – that provides ongoing symptom relief will take some time. Second-generation antipsychotics are recommended as first-line treatment because they are more effective than first-generation antipsychotics for treating negative, cognitive and depressive symptoms. The second-generation antipsychotic medications are:

• Olanzapine/Zyprexa  

• Risperidone/Risperdal 

• Quetiapine/Seroquel

• Clozapine/Clozaril

It’s important to know that around 30% of patients with schizophrenia show an inadequate response to antipsychotics.

Counselling and Psychotherapy

Counselling can help with many problems like low mood, anxiety, and relationships. You can learn helpful skills like problem-solving and setting goals. There are also therapies to help reduce the impact of delusions and hallucinations. Schizophrenia can affect people’s goals around education, work, and independent living. Professionals like occupational therapists and social workers can help with daily living, social skills, employment or volunteer training, and community activities. They can also connect you with community supports like home care, housing, and income assistance. A big part of managing schizophrenia is relapse prevention. You can learn what might trigger an episode and learn to recognize early warning signs of an episode. The goal is to learn when to seek extra supports, which may help reduce the impact or length of the episode. Self-care is important for everyone. Small steps like eating well, getting regular exercise, building healthy sleep habits, spending time on activities you enjoy, spirituality, and connecting with loved ones can make a big difference. Schizophrenia can leave people feeling very isolated and alone. At times, many people who experience schizophrenia feel uncomfortable around others. But many also worry about what others will think of them. The right relationships can be supportive and healing.

 Psychotherapy is geared on learning to focus on resiliency, managing the condition, promoting wellness and developing coping skills. Some form of individual psychotherapy, in combination with the prescription of antipsychotic medications, is likely the most common treatment for patients with schizophrenia. In psychosis, standardized treatment guidelines recommend psychotherapy (National Institute for Clinical Excellence (Nice,  2014). Recent research has demonstrated that a psychotherapy-focused treatment of schizophrenia (in combination with low doses of antipsychotic medication) is superior to the standard medication-driven treatment (Kane et al., 2016). Psychotherapies that involve the family have been known to improve outcomes in schizophrenia since the early studies of expressed emotion.

Cognitive-behavioral therapy (CBT) in schizophrenia was originally developed to provide additional treatment for residual symptoms, drawing on the principles and intervention strategies previously developed for anxiety and depression. CBT is indicated in schizophrenia.  Beck, in 1952, described successfully treating a delusional belief held by a patient with schizophrenia using CBT. According to the Beck Institute website (2016), “the goal of CBT is to help people get better and stay better.”

CBT for schizophrenia involves establishing a collaborative therapeutic relationship, developing a shared understanding of the problem, setting goals, and teaching the person techniques or strategies to reduce or manage their symptoms. A CBT therapist focuses on changing unhelpful patterns of thinking and behavior. CBT, having been adopted as a standard treatment in the United Kingdom for individuals with schizophrenia, is finally gaining more interest and acceptance in the United States as an adjunctive treatment for people with schizophrenia. One study comparing CBT to other forms of psychosocial interventions found that CBT and routine care together were more effective than any of the other therapies examined (Rector  & Beck, 2012).

Cognitive adaptation training

Schizophrenia is a heterogeneous disorder characterized by various symptom dimensions and neurocognitive deficits. People with schizophrenia may have cognitive symptoms that affect their ability to remember, focus, pay attention and solve problems. These symptoms can make it hard to carry out everyday functions, such as taking medication and self-care. Cognitive adaptation training (cat) uses individually customized supports, such as signs and checklists, to help people manage their daily tasks.

Psychosocial Rehabilitation

Like all people, individuals living with schizophrenia typically have important goals for themselves in the areas of relationships, work and living. Psychiatric rehabilitation strategies are designed to enable people to compensate for, or eliminate, the environmental and interpersonal barriers as well as the functional deficits created by this illness. The field of psychosocial rehabilitation helps people successfully live in independent housing, pursue education, find jobs and improve social interaction.  ACT, or PACT, known as Assertive Community Treatment, is an evidence-based, service-delivery model that provides comprehensive, locally based treatment to people living with serious mental illness such as schizophrenia. Available 24 hours a day, seven days a week, ACT professionals meet people where they live, providing at-home and in-community support at whatever level is needed. Professionals work with individuals living with mental illness to address problems proactively, helping to make sure that crises do not happen, ensure medications are being properly taken and assist in helping individuals meet the routine challenges of daily life, which is an important part of mental health recovery.

Impact on Caregivers  

The available data show that the proportion of persons with schizophrenia living with their relatives ranges between 40% in United States to more than 90% in China ( Torrey and Wolfe, 1986; Xiong et al., 1994). Moreover, family involvement and distress is not necessarily lower when the sufferer lives away from home (Winefield and Harvey, 1993). Nevertheless, the burden that is often placed on families or others living in close contact with a mentally ill person has only recently been recognized (Fadden et al., 1987). Various aspects of impact on caregivers should be considered, including:

 • the economic burden related to the need to support the patient and the loss of productivity of the family unit;

• emotional reactions to the patient’s illness, such as guilt, a feeling of loss and fear about the future; • the stress of coping with disturbed behaviour;

• disruption of household routine; • problems of coping with social withdrawal or awkward interpersonal behaviour;

• curtailment of social activities.

Various aspects of the caregiver’s burden have been reported across a variety of geographical and social settings. Financial loss associated with schizophrenia has been noticed in countries as different as Laos and United Kingdom (Westermeyer, 1984; Davies and Drummond, 1994). The manifold facets of burden hinder any overall evaluation, making it difficult to identify factors that are likely to influence it. A summary list includes patients’ and caregivers’ characteristics, family size and economic status, role expectations and illness-related beliefs. Such wide variability, combined with cross-cultural differences, leads to estimates of prevalence of family burden ranging between 30% and 80%. There is a widely held belief that distress is more often related to patients’ apathy, inactivity or failure to comply with social duties, than with more evident positive psychotic symptoms or behavioural disturbances (Leff and Vaughn, 1985). However, this may not be true in all social or cultural groups. According to a recent survey in Malaysia, in which subjective emotional burden has been found in 41% of families, hostility, violence and disruption of family activities were perceived as the main source of stress (Salleh, 1994).

Family therapy and supports

Having a supportive family can be a huge help to people with schizophrenia. However, family members themselves often experience significant stress. This can make it harder for them to be supportive and to take care of themselves. Individual and family counselling, psychoeducation workshops and support groups can help people to develop coping strategies and effective communication skills, which allow them to better support the family member and to practice self-care.

Remission in Schizophrenia

Remission is commonly used in clinical practice to describe the stable state of schizophrenic patients. Remission has been defined as a level of symptomology that does not interfere with an individual’s behaviour, and is also below that required for a diagnosis of schizophrenia. Symptom improvements should last for a minimum of six months in order for remission to be reached. Recovery is less precisely defined. In addition to the symptom improvements required for remission, improvements in social and functional dimensions are required. These domains usually include, but are not restricted to; functional independence, maintaining satisfying relationships, being productive, having a sense of empowerment, and overcoming feelings of internalised stigma. Improvements in either clinical or functional domains need to be seen for at least two years.