Schizophrenia
“Schizophrenia...remains ones of the most frightening diseases
known to mankind. To an observer, the bizarre behaviors and speech
of a schizophrenic are disturbing. For the schizophrenic, the world is
a confusing maze of nightmares from which one cannot wake up.”
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Schizophrenia
About Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Definitions
History
Causes
Epidemiology
Additional Information
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Positive
Negative
Cognitive
Affective
Subtypes of Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Paranoid Subtype
Disorganized Subtype
Catatonic Subtype
Undifferentiated Subtype
Residual Subtype
Phases of Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Acute phase
Stabilization phase
Stable phase
Diagnostic Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Specific Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Medication
Therapy
TR Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
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About Schizophrenia
Definitions:
“A severe mental disorder characterized by some, but not necessarily all,
of the following features: emotional blunting, intellectual deterioration, social
isolation, disorganized speech and behavior, delusions, and hallucinations.”
- Dictionary.com
“A psychotic disorder characterized by loss of contact with the
environment, by noticeable deterioration in the level of functioning in everyday
life, and by disintegration of personality expressed as disorder of feeling, thought
(as delusions), perception (as hallucinations), and behavior —called also
dementia praecox” - Merriam-Webster Dictionary
“A psychotic disorder (or a group of disorders) marked by severely
impaired thinking, emotions, and behaviors. Schizophrenic patients are typically
unable to filter sensory stimuli and may have enhanced perceptions of sounds,
colors, and other features of their environment. Most schizophrenics, if untreated,
gradually withdraw from interactions with other people, and lose their ability to
take care of personal needs and grooming.”- Farlex Medical Dictionary
History:
In 1893, Schizophrenia was first identified by German psychiatrist, Emil
Kraepelin. Before Kraepelin, doctors had divided this mental disorder into three
types. The first “disorder,” hebephrenia, which is characterized by extremely
disorganized thoughts and difficulty carrying a rational conversation. The second,
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catatonia, involves unmoving in bizarre positions. The third, paranoia, comprises
of an obsession that people or things are out to harm the individual.
Kraepelin combined these three categories into a single disease and
named it Dementia Praecox, which roughly translates to “demented early”
because it was seen predominantly adolescents. Kraepelin believed that
schizophrenia stemmed from deterioration in the brain. Swiss psychiatrist Eugen
Bleuler noted that some people recovered from this disease for no apparent
reason, thus it was not a degeneration of the brain. In 1911, Bleuler renamed the
disease to the current term “schizophrenia” because he believed it involved a
psychological splitting. “Schism” is Greek for split” and “phrenic” refers to the
mind or brain (Abramovitz, 2002, p.16). It is important to note that schizophrenia
is NOT the same as split-personality disorder, which is a common misconception
prevalent in our society today.
Causes:
“Ever since schizophrenia was identified as a disease, experts have
debated its causes” (Abramovitz, 2002, p. 28). Some scientists believed the
onset of schizophrenia came from biological factors in the brain. Others
supported the idea of psychological abnormalities as the main cause, and still
others held that social and environmental factors were to blame. Sigmund Freud,
a well-known psychologist from Vienna believed that a person’s unconscious
memories of traumatic childhood experiences caused schizophrenia. After
studying the disease extensively, Dr. Frieda Fromm-Reichmann, a German
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psychiatrist and contemporary of Freud, connected the development of
schizophrenia in adolescents to a cold and distant mother (Abramovitz, 2002, pg.
28). Schizophrenia has also been studying in relation to genetics, family ties,
brain abnormalities, prenatal damage, and neurotransmitters.
A 1920 U.S. study using twin pairs found that schizophrenia developed in
identical twins 58% of the time. In comparison, only 15% of the fraternal twins did
(Abramovitz, 2002, p. 31). In addition to genetics, there has also been a case
made for family ties. According to Abramovitz, people with one schizophrenic
parent were 8-18% more likely to develop schizophrenia themselves. People with
two schizophrenic parents were 46% more like to develop it in later years
(Abramovitz, 2002, p. 32).
In regards to brain abnormalities, people with schizophrenia have
decreased size in the hippocampus which affects the ability to learn, and
decreased size in the amygdala which controls aggression and sensory and
emotional processing (Abramovitz, 2002, p. 35). Prenatal damage to the brain
may also play a significant role in the onset of schizophrenia. Abramovitz states,
“There is considerable evidence that difficult childbirth may result in brain
damage associated with the disease in an individual who are predisposed to
schizophrenia because of heredity.” Breech birth, the use of forceps during
delivery, prolonged labor, and lack of oxygen to the fetus are all associated with
high incidence of schizophrenia in later life (Abramovitz, 2002, p. 36).
Researchers are currently looking more closely at the role neurotransmitters play
in the brains of people with schizophrenia. PET scans show that people with
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schizophrenia have abnormal levels of neurotransmitters in the brain compared
to the brains of those who do not have the condition. They especially have
excesses of dopamine. When researchers gave injections of dopamine to clients
in a study their symptoms worsened considerably (Abramovtiz, 2002, p. 40).
Epidemiology:
Epidemiology is the trends and cultures an illness or disease has in a
group or society. Schizophrenia effects 1% of US Citizens, which is rising each
year with 1.5/10,000 people being diagnosed and effects more men than women
(1.4:1). The onset of schizophrenia happens between the ages 21-25 for males
and 25-32 for females. (Javed, 2010). Those who have been diagnosed with
Schizophrenia are also usually found to live in urban areas, immigrated at some
point in their lives, have obstetrical complications, and were born in either late
winter or early spring-time birthday (potentially due to influenza exposure during
neural development.) Lastly, about ⅓ of homeless adults in the US suffer from
Schizophrenia. This is not because homelessness leads to this illness, but that
those who suffer from schizophrenia end up on the streets.
Additional Information (facts, demographics, statistics, history):

Schizophrenics are more prone to early death from infections, heart
disease, diabetes, breast cancer, and other illnesses. Experts believe this
is because medical personnel are more likely to ignore schizophrenic’s
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complaints because they believe they are imaginary and a result from the
person’s mental malfunctions.

10 to 13% of schizophrenics commit suicide as a result of being
depressed with the prospect of living with an endless cycle of terror.
(Abramovitz, 2002, p.11)

One of the major challenges doctors face with this severe mental disorder
is convincing the person that they do need help. (Abramovitz, 2002, p. 12)

Schizophrenia is a chronic, severe, debilitating mental illness that affects
about 1% of the population, more than 2 million people in the United
States alone.

Schizophrenia is considered the most chronic, debilitating, and costly
mental illness

People with schizophrenia are far more likely to harm themselves than be
violent towards the public.
Symptoms
Symptoms of schizophrenia are divided into four classifications. They are as
follows:
Positive:
This category includes psychotic delusions, which are the most common
symptom of schizophrenia. It also includes hallucinations. Hallucinations involve
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hearing, seeing, or sensing things that do not actually exist in reality. Auditory
hallucinations are most common and usually involve the individual hearing voices
inside their head that they perceive to be real. In addition to hallucinations,
persons displaying positive symptoms of schizophrenia may also exhibit
inappropriate behaviors such as laughing at the news of a tragedy, undressing in
public or in front of strangers, walking in repeated motions or patterns, shaking
the head, rolling the tongue, jerking the arms and legs, and stumbling and
knocking things over (Abramovitz, 2002, p. 13-14).
Negative:
This category includes the absence of behaviors and emotions present in
normal people. Some examples of this would be lack of facial expressions, lack
of automatic movements (blinking, swinging arms when walking), refusal to make
eye contact, refusal to speak or speaking very slowly, and failure to experience
emotions such as happiness or sadness (Abramovitz, 2002, p. 14).
Cognitive:
This category includes problems with thought processes. Individuals who
display this symptom type experience difficulty in making sense of information,
difficulty with focus, as well as memory problems.
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Affective:
This category involves changes in an individual’s mood. Depression and
mood swings are common occurrences with this symptom. Odd behaviors such
as these, however, may eventually lead to social aversion and painful isolation.
Subtypes of Schizophrenia
Paranoid Subtype:
Paranoid schizophrenia is the most common type diagnosed. This type is
characterized by the presence of auditory hallucinations or prominent delusional
thoughts about persecution or conspiracy. However, people with this subtype
may be more functional in their ability to work and engage in relationships than
people with other subtypes of schizophrenia.

They are very suspicious of their surroundings and those they interact with

Tend to be more functional in their ability to work and engage in
relationships

Symptoms usually not exhibited until later in life, therefore the person has
already achieved a higher level of functioning before the onset of their
illness.

Hallucinations and delusions typically revolve around a characteristic or
theme

Tend to exhibit anger, anxiety, and argumentativeness
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Disorganized Subtype:
Disorganized schizophrenia is characterized by the disorganization of the
thought process. Because of this difficulty processing thoughts and expressing
ideas they seem childlike and incompetent in maintaining activities of daily life.

Hallucinations and delusions not usually present

Significant impairments on routine tasks such as dressing, bathing,
brushing teeth, etc.

Appear to be emotionally unstable

Child-like behavior

Inappropriate laughter/emotions (flat affect)

Incoherence in speech

Repetitive behaviors
Catatonic Subtype:
Catatonic schizophrenia is characterized by disturbances in movement
commonly seen in a state of inactive, rigid posture.

Agitation

Decreased sensitivity to pain

Inability to take care of personal needs

Repetitive purposeless actions

Parrot-like repeating of what others are saying or doing
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
Negative feelings

Socially withdrawn

Motor disturbances, such as unusual facial contortions or limb movements

Rigidity

Stupor

Remain in poses/positions for abnormal amounts of time, exhibiting
considerable physical strength (waxy flexibility)
Undifferentiated Subtype:
Undifferentiated schizophrenia is classified as the patient contains the
general criteria for schizophrenia but does not conform to one of the above
subtypes. They exhibit features of multiple subtypes without a clear dominance in
one.
Residual Subtype:
Residual schizophrenia is classified when the person is no longer suffering
from delusions, hallucinations, or disorganized speech and behavior, but lacks
motivation and interest in day-to-day living.
Phases of Schizophrenia
In addition to sub-types, there are also phases of schizophrenia. (Abramovitz,
2002, p. 21-22)
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Acute phase:
This phase includes active symptoms such as hallucinations, delusions,
catatonia, disorganized thoughts, and negative symptoms. This phase can last
anywhere from a few hours to several years.
Stabilization phase:
This phase occurs when acute symptoms decrease and the person
regains the ability to function more or less normally. This phase lasts anywhere
from six months or more.
Stable phase:
This phase occurs when symptoms are absent or much less severe than
in the acute phase. It is important to note that not all patients will get past the
acute phase and that others can remain in the stable phase for a stretch of time.
Diagnostic Criteria
Most psychiatrists today base their diagnosis on the length of time a
patient has had symptoms of schizophrenia. They also examine and take into
account how severe the symptoms are. Psychiatrists refer to the fourth edition of
the Diagnostic and Statistical Manual of Psychiatry (aka DSM-IV) to make a
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diagnostic. In order to be diagnosed as having schizophrenia, an individual must
display one of the following:
 The patient must have some psychotic symptoms for at least 6 months
 The patient must have two or more active symptoms for at least one
month
 The patient must have an inability to interact with others and work
productively (Abramovitz, 2002, p. 23-24).
Diagnoses can be influenced by culture. For example, doctors in India are
less likely to diagnose someone as schizophrenic because they believe someone
who experiences hallucinations and other delusions is a spirit medium or avatar
who permanently takes on the role of a Hindu god. Likewise, in Japan doctors
are less likely to diagnose someone as schizophrenic even if they display the
symptoms because of a strong cultural aversion to do anything that might reflect
negatively on the patient’s family. They especially want to avoid the stigma of
mental illness (Abramovitz, 2002, pg. 25).
As far as tests go, there is no test that can make a diagnosis for
schizophrenia. According to WebMD, “People with schizophrenia usually come to
the attention of a mental health professional after others observe them behaving
strangely. Most people with schizophrenia will have at least some of its main
symptoms” (WebMD, 2012). For a psychiatrist to make a confident
schizophrenia diagnosis, some of these symptoms should be present:

Hallucinations. This means hearing voices or other sounds that aren't
there or seeing things that don't exist.
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
Delusions (unshakeable beliefs that aren't true).

Disorganized speech and behavior (talking and acting strangely).

Lack of motivation and emotional expression.

Lack of energy.

Poor grooming habits.
Specific forms of the main symptoms, when present, make a schizophrenia
diagnosis more likely. These include:

Hearing your own thoughts spoken aloud.

Feeling that thoughts are being inserted into your mind, or removed from
it, by an outside force.

Feeling like other people can read your mind.

Feeling that an outside force is making you feel something, want
something, or act in a certain way.


Hearing voices discuss you or argue about you.
Hearing voices narrate your actions as you perform them.
A person experiencing schizophrenia may describe these symptoms openly. A
psychiatrist may also assume they are present based on observations of a
person's speech and behavior. (WebMD, 2012).
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Prognosis
“One important prognostic sign is the patient's age at onset of psychotic
symptoms. Patients with early onset of schizophrenia are more often male, have
a lower level of functioning prior to onset, a higher rate of brain abnormalities,
more noticeable negative symptoms, and worse outcomes. Patients with later
onset are more likely to be female, with fewer brain abnormalities and thought
impairment, and more hopeful prognosis.
The average course and outcome for schizophrenics are less favorable
than those for most other mental disorders, although as many as 30% of patients
diagnosed with schizophrenia recover completely and the majority experience
some improvement. Two factors that influence outcomes are stressful life events
and a hostile or emotionally intense family environment. Schizophrenics with a
high number of stressful changes in their lives, or who have frequent contacts
with critical or emotionally over-involved family members, are more likely to
relapse. Overall, the most important component of long-term care of
schizophrenic patients is complying with their regimen of antipsychotic
medications.” -Flexar Medical Dictionary
Specific Needs
People living with schizophrenia need a correct diagnosis and early
treatment of their illness. They need understanding, compassion, respect, and an
effective, functioning mental health system. Like anyone else living with a
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serious, ongoing illness, a person living with schizophrenia needs help with the
fear and isolation associated with this illness as well as the negative cultural
attitudes surrounding it. Some who live with this illness need help with their
physical care, as dealing with schizophrenia can make even the everyday tasks
of life difficult, from staying clean and eating well to following medical treatment.
Many people with schizophrenia need long term help with basic needs.
Treatment
Schizophrenia is considered a lifelong condition which rarely is “cured”,
but rather treated. Over the years, medication has proven to help manage
schizophrenia’s symptoms, that does not, however, mean that medicine is the
only part of the overall treatment of this illness. Successful treatment of
schizophrenia depends upon a lifelong regimen of both medication and
psychotherapy. The therapy is needed to help the person find a job, learn to be
effective in social relationships, increase the individual’s coping skills, and help
them learn to communicate and work well with others.
Medication:
Antipsychotic medications have been found to be most successful in the
treatment of schizophrenia. These medications have been found to effectively
alleviate the positive symptoms of schizophrenia. People respond differently to
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the drugs, so sometimes it is necessary to try several different kinds before the
right one is found.
In light of the lifelong nature of schizophrenia, it requires a lifelong need
for medication to keep their symptoms under control. Most often patients are
started on a high dose of medication to bring their symptoms under control. Then
over time their doctors are able to reduce that dosage to a lower level, which is
still able to maintain control over those symptoms and prevent future episodes.
Several side effects have been observed, but tend to go away after the first days.
Symptoms in first days:

Drowsiness

Dizziness

Blurred vision

Develop a rapid heartbeat

Menstrual problems

Sensitivity to the sun

Skin rashes
New drugs, called atypical antipsychotics, have been developed to help
alleviate some of the side effects of older drugs.
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Atypical Antipsychotics:

Clozapine

Risperidone

Olanzapine

Quetiapine

Sertindole

Ziprasidone
Some side effects of these drugs include:

Weight gain

Metabolic changes

Increased risk of diabetes

High cholesterol

Drowsiness

Restlessness

Slowed movements

Shakes

Long term use can cause an increased chance of Tardive Dyskinesia, an
untreatable movement disorder
Therapy:
Psychosocial treatments can help patients who are already stabilizing on
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antipsychotic medications deal with communication, motivation, self-care, work,
and establishing and maintaining relationships with others. Learning and using
coping mechanisms to address these problems allows people with schizophrenia
to attend school, work, and socialize. A positive relationship with a therapist gives
the patient a reliable source of informations, sympathy, encouragement, and
hope.
There are several different types of therapy, which include family psychoeducational, assertive community treatment, substance abuse treatment, social
skills training, supported employment, cognitive behavioral therapy, and weight
management. Self-help groups and networking are also used as a therapeutic
method for support and comfort.
Family psycho-educational:
Patients with schizophrenia are often discharged from the hospital into the
care of their family. In addition to educating family members about the symptoms,
course, and treatment of schizophrenia, this form of treatment consists of
providing family support, problem-solving skills, and access to care providers
during times of crisis. When this intervention is consistently provided for at least
several months, it has been found to decrease the relapse rate for the individual
with schizophrenia and improve the person’s social and emotional outcomes.
Also, the burden that family members experience as a result of having a loved
one with schizophrenia is lessened. Family members tend to be more
knowledgeable about the disorder and feel more supported by the professionals
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involved, and family relationships are improved.
Assertive community treatment:
This intervention consists of members of the patient’s treatment team
meeting with that individual on a daily basis, in community settings, for example,
home, work, or other places the patient frequents, rather than in an office or
hospital setting. The treatment team is made up of a variety of professionals.
This can include a psychiatrist, nurse, case manager, employment counselor,
and a substance abuse counselor. Assertive community treatment (ACT) tend to
be successful in reducing how often people with schizophrenia are hospitalized
or become homeless.
Substance abuse treatment:
Providing medical and psychosocial interventions that address substance
abuse should be an integral part of treatment as about 50% of individuals with
schizophrenia suffer from some kind of substance abuse or dependence.
Social skills training:
Social skills training is also referred to as illness management and
recovery programming and involves teaching clients ways to handle social
situations appropriately. It often involves the person scripting situations that occur
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in social settings in order to prepare for those situations when they actually
occur. As part of illness management they are taught basic facts about
schizophrenia helping them to make informed decisions about their care and
monitor early warning signs of relapse. This treatment type has been found to
help people with schizophrenia resist abusing drugs, as well as improve their
relationships with healthcare professionals and coworkers.
Supported employment:
This intervention provides supports such as a work coach, someone who
counsels the client in the workplace, as well as instruction on constructing a
resume, interviewing for jobs, and education and support for employers to hire
individuals with chronic mental illness. Supported employment has been found
help schizophrenia patients secure employment, earn more money, and increase
the number of hours they are able to work.
Cognitive behavioral therapy:
Cognitive behavioral therapy (CBT) is a reality-based intervention that
focuses on helping a client understand and change patterns that tend to interfere
with his or her ability to interact with others and otherwise function. CBT is useful
for patients with symptoms that persist even with the use of medication. This
method teaches patients how to test the reality of their thoughts and perceptions,
how to “not listen” to their voices, and how to shake off the apathy that often
immobilizes them. It appears to be effective in reducing the severity of symptoms
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and decreasing the risk of relapse.
Weight Management:
Educating people with schizophrenia about weight gain and related health
problems that can be a side effect of some antipsychotic and other psychiatric
medications has been found to be helpful in resulting in a modest weight loss.
That is also true when those with schizophrenia are provided with behavioral
interventions to assist with weight loss.
Self-Help Groups and Networking:
By using these methods they can see that they are not alone in dealing
with schizophrenia and feel less isolated. These groups are for people with
schizophrenia and their families. Professional therapists are not involved, leaving
those with schizophrenia and their families to take charge and run the groups.
TR Implications
Therapeutic recreation can be used as an effective treatment to reduce
the symptoms of schizophrenia and improve the quality of life for those dealing
with it.
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Benefits therapeutic recreation can offer a person with schizophrenia:

Learn how to manage stress and coping strategies

Aid in sharing thoughts more easily

Learn to enhance friendships and relationships

Find activities to enjoy during free time

Rehabilitation

Help learn skills necessary to be successful and home, work, or school

Meaning and purpose in life can help people avoid indulging in their
delusions
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References
Abramovitz, M. (2002). Diseases and disorders: Schizophrenia. (pp. 8-40). San
Diego, CA: Lucent Books.
Bengston, M. (2006). Types of Schizophrenia. Psych Central. Retrieved from
http://psychcentral.com/lib/2006/types-of-schizophrenia/
Edwards, R.D. (2011). Schizophrenia. Retrieved from
http://www.medicinenet.com/schizophrenia/page5.htm
Farlex. (2012). Schizophrenia. The Free Dictionary: Medical Dictionary.
Retrieved from http://medical-dictionary.thefreedictionary.com/
Schizophrenia
Fischer, B. & Buchanan, R. (2012). Schizophrenia: Epidemiology and
Pathogenesis. Wolters Kluwer Health. Retrieved from http://www.
uptodate.com/contents/schizophrenia-epidemiology-and-pathogenesis
Grohol, J. (2011). Schizophrenia treatment. Retrieved from
http://psychcentral.com/disorders/sx31t.htm
Javed, M. (2010). Gender and Schizophrenia. Journal of Pakistan Medical
Association. http://www.jpma.org.pk/full_article_text.php?article_id=2907
Smith, M., & Segal, J. (2012). Schizophrenia: Understanding the signs,
symptoms, and causes. Retrieved from http://www.helpguide.
org/mental/schizophrenia_symptom.htm
WebMD. (2012). Schizophrenia diagnosis. Retrieved from
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http://www.webmd.com/schizophrenia/guide/schizophrenia-tests
(2012). Schizophrenia. Merriam-Webster: An Encyclopedia Britannica
Company. Retrieved from http://www.merriamwebster.com/dictionary/schizophrenia
(2012). Schizophrenia. Dictionary.com. Retrieved from <http://dictionary.
reference.com/browse/schizophrenia>
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