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Schizophrenia is unfortunately one of those mental disorders that suffers from not only distorted media headlines but the affects of popular culture with over 70% of characters on television with said disorder portrayed as being violent with more than one in every five being portrayed as a murderer. Contributions from these sources have helped create the commonly held belief that not only does schizophrenia mean a sufferer has a split personality but that people with this disorder are dangerous. The truth of the matter is, and research supports these facts, that people who suffer from schizophrenia are no more violent than people who do not have the illness.

Characterised by a broad spectrum of cognitive and emotional dysfunctions schizophrenia includes such positive, negative and disorganised symptoms as delusions, hallucinations, disorganised speech and behaviour as well as inappropriate emotions. As you can imagine, the effect of this on both the individual with the illness as well as family and friends can be, and usually is, detrimental and devastating.

In addition to this, and unfortunately for the people with this illness, they are often completely devalued by society and are twice as likely to be harassed by strangers. This, one finds completely disturbing, the idea of harassing anyone, let alone somebody who may appear ‘crazy’, just demonstrates the callous nature of certain ne’er-do-well’s in society.

It has been estimated that the financial cost of schizophrenia is also immense – greater than most people would care to believe. The annual cost is theorised to be in the hundreds of billions of dollars due to not only lost wages due to sufferers not being able to work, but also due to costs involved in family caregiving or treatment.

With an immense amount of research having already been completed, as is the case with most common mental illnesses, there is still no firm ‘What is schizophrenia?’ answer with the illness being complicated by a large array of symptoms that include a number of schizophrenia ‘subtypes’.

History
German psychiatrist Emil Kraeplin took work done by a number of individuals and expanded on it (John Haslam’s 1809 book ‘Observations on Madness and Melancholly’, Phillippe Pinel’s observations of the same year as well as Benedict Morel whose work was conducted more than fifty years later). The end result of this was two fantastic achievements in the field of mental illness study, both of which occurred in 1898.

Firstly he was able to take several symptoms of insanity viewed as being separate and combine them. These were catatonia (alternating immobility and excited agitation), hebephrenia (sill or immature emotionality – like laughing at a funeral) and lastly paranoia (delusions of grandeur or delusions of persecution).

The second thing Kraeplin was able to do was distinguish the illness from bipolar disorder (what used to be called manic depression). He gave the ‘new’ illness the name dementia praecox and focused on the early onset of symptoms and the typical poor outcomes of individuals who have it. He was able to separate it from bipolar disorder by citing numerous different symptoms that were not present in those cases.

The second major figure in the history of schizophrenia is a Swiss psychiatrist by the name of Eugen Bleuler. He was also the first person to pen the term ‘schizophrenia’ which comes from the Greek words ‘skhizein’ meaning split and ‘phren’ meaning mind. This change in terminology also signalled a departure from Kraeplin’s way of thinking when it came to the core problem behind the disorder. Bleuler believe that there was an ‘associative splitting’ of basic personality functions when it came to schizophrenia with the concepts emphasising a ‘breaking of associative threads’. This is basically referring to destruction of the forces that connect one function to the next within the brain. Bleuler also believed that being unable to maintain a consistent train of thought was very indicative of the disorder and this may also contribute to the diverse and many symptoms displayed by persons suffering from schizophrenia.

Identification
Identification of those people who are suffering from schizophrenia has always been a very difficult task due mostly to the vast array of symptoms that they exhibit in that these symptoms do not fit neatly into a little box. There are also a number of behaviours and symptoms that are exhibited by persons with this illness that aren’t necessarily shared by all people diagnose with schizophrenia with the causes of the illness also found to vary widely across individuals.

Despite these obvious complexities and issues clusters of symptoms were able to be identified; they were given three groups – positive, negative, as well as disorganised. Unfortunately though, as can be imagined with such a complex mental illness as schizophrenia there is no universal agreement as to what should be included as symptoms. However, as previously stated the three indentified groups are positive symptoms, which are active symptoms such as hallucinations, negative symptoms which are deficits such as lack of speech or motivation, and finally disorganise symptoms which include erratic behaviour or inappropriate affect (laughing at an inappropriate time). Diagnosis requires that individuals be exhibiting two or more symptoms for at least a month.

Positive Symptoms
Delusions: Technically these are called a disorder of thought content, but are commonly called delusions; they involve a misrepresentation of reality and are referred to as the basic characteristic of madness. If you think that all insects on the planet are actually robot aliens controlled from the moon you would generally be perceived as delusional.

Within delusional symptoms there are a number of subgroups. Firstly there are delusions of persecution which basically means that you think people are out to get you. If you believe that all the traffic on the road during peak hour is actually put there just to stop you from getting to work then you probably have delusions of persecution. Another symptom is called Capgras Syndrome and this is where you believe a person that you know has been replaced by a double or a clone. Thirdly there is Cotard’s syndrome where the sufferer believes that their body has changed in some impossible way, for instance, you have wings and can actually fly. Lastly there are delusions of grandeur where the person with schizophrenia believes they are the president of a country or are a reincarnation of Jesus.

Research suggests that some of these delusions may be adaptive, to a certain extent only of course. Deluded individuals have a much stronger sense of purpose and life meaning and are generally less depressed as their delusions influence how they feel about themself, although this is still just a theory.

Hallucinations: These would have to be one of the most terrifying and complex symptoms of schizophrenia – having experienced hallucinations oneself due to fever one can understand how these individuals feel from day to day. They are defined as a sensory event that has no environmental input. Some individuals will hear their name being called, other sufferers will see something that’s not there with hallucinations able to theoretically affect any of the senses however auditory hallucinations are the most common. More often than not people with this mental illness will show overt signs of auditory hallucination, that is, physical signs that can be witnessed – this means that those around a sufferer of schizophrenia can often be the first point of call in diagnosing the disease. Sufferers will possibly, depending on their level of hallucination, begin talking to people that aren’t there, or will laugh or acknowledge comments or conversations that don’t exist. Additional research suggests that auditory hallucinations are more frequent when unoccupied or are in a zone where sensory input is restricted.

Recently, researchers from London used a new technique called Single Photon Emission Computed Tomography (SPECT) to study the cerebral blood flow of men with schizophrenia. It was found that Broca’s Area was the most active brain area during hallucinations which is known to be used in speech production. This was surprising was it was theorised that Wernicke’s Area would be the more active area of the cortex given that this area is involved with language comprehension.

This supports the hypothesised theory that auditory hallucinations could actually be the sufferer hearing their own thoughts or their own voice and they cannot tell the difference between the two. It is highly possible that deficits in speech processing result in these distortions but more research needs to be conducted to confirm these assumptions. Thankfully, advances in brain imaging technology are giving researchers a much greater observation into the activity of the cortex during periods of hallucination.

Negative Symptoms
About 25% of persons with schizophrenia will display negative symptoms also. They are called negative symptoms because of the effect they have on the individual, that is, negative symptoms basically take something away from the person as you will see in a moment.

Avolition (also called apathy): Combines ‘a’ which means without and ‘volition’ meaning to decide or choose etc. Avolition is described as the inability of a person with the illness to initiate or persist in activities – they generally have little to no interest in anything including basic day to day functions of life including but not limited to personal hygiene.

Alogia: Another negative symptom experienced by persons with schizophrenia is alogia – this comes from once again ‘a’ meaning without and ‘logos’ meaning words. This symptom is described as the relative absence of speech; sufferers will usually offer short replies to questions, even open questions, with little or no content or information and they will often appear uninterested. It has been hypothesised that alogia is representative of a negative thought disorder. Research suggests people with this symptom may have trouble finding the words to formulate their thoughts as it sometimes takes the form of delayed comments, that is, they are slow to answer questions. As you can imagine it can become quite frustrating talking to such individuals as it is very difficult to maintain a conversation with them.

Anhedonia: This symptoms meaning is derived from the word ‘hedonic’ which pertains to pleasure. Persons with anhedonia are presumed to lack the experience of pleasure. They have a varying amount of indifference to activities, similar to some mood disorders, that are usually considered to be pleasurable by people including things such as eating food, social interactions and even sexual relations.

Affective Flattening: What is meant by having a flat affect is that there are no emotions visible. Sufferers will generally also have no reactions to emotional events that show overtly and they commonly stare vacantly and have a flat or monotone speaking voice. As stated, they will not show any physical signs of emotional events affecting them but they may still have internal reactions to these events. Research has shown that people with flat affect still have the appropriate internal emotional response but they may simply have a problem expressing their emotions, not a lack of feeling. Other research mimicked these results and took it to the next level by using imaging techniques to observe physiological responses – which verified their behavioural observations.

This symptom may also be one of the more important ones when it comes to early diagnosis of people suffering schizophrenia as other research has shown. Researchers studied the facial expressions of children who later developed schizophrenia and compare them with their brothers and/or sisters that did not develop the illness. Those that grew up and developed the illness were found to show less positive and more negative affect than their siblings. This suggests emotional expression can be a handy tool in the diagnosis of schizophrenia.

Disorganised Symptoms
The disorganised symptoms are the least studied of all schizophrenias array of symptoms and are hence also the least understood

Disorganised Speech: People with disorganised speech also often lack insight, which means that they do not have any awareness that they actually have a problem. They tend to jump from topic to topic, talking in an illogical manner while often through no fault of their own avoid answering questions (commonly called tangentiality). Rather than answering the question that has been asked they will step sideways and go down a completely different avenue changing the conversation to unrelated areas. As can be imagined it is difficult to interpret the meaning of or issue surrounding the conversations. For example, if you ask someone suffering from disorganised speech a question about a relative that has passed away, and they respond as if the person is still alive while changing the topic completely it is near impossible to understand the reason for this – is it just random? Do they do it to avoid talking about the deceased? Or something different again? No real answers can be concluded.

Inappropriate Affect / Disorganised Behaviour: People who exhibit this symptom are known to not only hoard items but will act unusually in public places. Catatonic state varies from immobile at the one extreme to agitated at the other. Those at the agitated end of the scale may pace around excitedly or move their arms or fingers in stereotyped ways while those at the other end of the spectrum will remain motionless for long periods of time and hold unusual postures. They also exhibit what is referred to as waxy flexibility – this is similar to holding unusual postures but it is where another person can put them in a position, which they continue to hold with no additional contact.

Subtypes
Now that you know the history as well as methods of identification and symptoms for schizophrenia it is time to touch on the different subtypes.

Paranoid: People with the paranoid type of schizophrenia stand out mostly because of their delusions and hallucinations. Their cognitive abilities and affect are relatively intact and they typically have a better prognosis than sufferers of other subtypes. Generally speaking, their delusions and hallucinations will revolve around a central theme, the most common themes involving either grandeur or persecution. The DSM-IV-TR classification requires that an individual with paranoid schizophrenia have a preoccupation with their delusions or hallucinations without any disorganised speech, disorganised or catatonic behaviour or any flat or inappropriate affect.

Disorganised: Those individuals with the disorganised group of symptoms have a marked disruption of speech and behaviour with flat or inappropriate affect. They can be unusually self absorbed to the point where some individuals will spend a considerable amount of time staring at their own image in a mirror. If they also suffer from delusions or hallucinations they are not centred around a particular theme as is the case in the paranoid subtype. Signs of this type of schizophrenia can also begin to be seen earlier on in life than other types and often has a chronic onset with little to no chance of remission.

Catatonic: The last major subtype is referred to as the catatonic subtype. Its main symptoms operate on two opposing poles; at one end you have waxy flexibility as well as oppositional ‘behaviour’ through remaining rigid for long periods of time while at the other end of the scale you will witness excessive activity engagement. People with this illness subtype will also demonstrate odd mannerisms with their body and face including grimacing, they can exhibit a phenomena called echolalia (the echoing or mimicking of others words) as well as another phenomena called echopraxia (mimicking the actions of other people). The clusters of behaviours are relatively rare though and debate rages as to whether catatonic should be its own subtype or not. Those that support leaving the subtype as it is site the effective nature of neuroleptic medications (more commonly called antipsychotics)

Undifferentiated: There are of course persons who do not fit into any particular subtype as while they have all the major symptoms of schizophrenia they do not have enough specific symptoms to be classed as either paranoid, disorganised or catatonic.

Residual: Lastly there is the residual subtype, and this is simply comprised of people who have had one onset of symptoms but they do not currently display any major symptoms of schizophrenia. They may however display leftover behaviours, or still have negative beliefs or unusual ideas. They may also withdraw from social situations, have bizarre thoughts, exhibit a flat affect and be inactive in general.

Where Can I Find Help?
Obviously the best person to talk to would be a qualified therapist. No matter where you live in Australia you can go here http://www.findapsychologist.org.au/. This is a service managed by the Australian Psychological Society and would be the best point of call.

The downside to this type of help is that it can be pricey, and given that most people with this disorder are unlikely to want to attend you might be better off speaking to community groups or free health clinics. Another really good place to get help is from SANE Australia. They can be contacted on 1800 18 SANE (7263) between the hours of 9am and 5pm, Monday to Friday. They can then give you information and contact details for services in your area.

If you live outside of Australia things get even more complicated due to the size of some countries. The easiest advice i can give you if you live in America is to go to http://www.mentalhealthamerica.net where you can be referred to other services both community clinics as well as single practitioners.

Other countries can also try the Open Directory available at http://www.dmoz.org as they have a very in depth directory based around location and the type of service you are looking for.