Schizophrenia

People with schizophrenia have what are called "positive" and "negative" symptoms. This doesn't mean the symptoms are good or bad. Positive symptoms are called "positive" because they're seen as being added to what a normal person has -- like hearing voices that nobody else hears. Negative symptoms are called "negative" because they're seen as qualities that are being lost -- like the ability to laugh and show emotion.

What are the positive symptoms?

Hallucinations – Auditory hallucinations (abbreviated "A/H") are by far the most common and cause the most problems. These are voices or sounds people hear that aren't really there. Sometimes the voices tell people to do things. These are called command hallucinations.

Delusions – Beliefs people hold with absolute certainty, even though they seem strange to other people and can easily be proven wrong. Delusions often become obsessions that preoccupy client's thoughts.

Paranoia - Intense anxiety and irrational fears, usually related to auditory hallucinations and delusions people have.

Disorganized thinking – Speech that doesn't communicate what the client intends, and behavior that doesn't make sense. Disorganized thinking also makes it hard to follow directions and understand things people are telling them.

What are the negative symptoms?

Apathy – People with schizophrenia sometimes appear to have little or no interest in the world around them. They may stop showering and changing clothes. Sometimes they can't will themselves to start things. This is called "avolition". It makes holding a job or going to school very difficult.

Anhedonia – An inability to experience pleasure. People with schizophrenia have described this as a feeling of being hollow or empty regardless of what they do. It's one of the main reasons people with schizophrenia have difficulty forming close relationships. Combined with apathy, it results in people avoiding social situations and choosing to spend their time alone.

Flat or inappropriate affect – "Affect" is the outward expression of our feelings and emotions. Most of us have what's called "broad" or "full range" affect. That means we laugh when we hear something funny, smile when we're happy, and look angry when we're mad. But when people have schizophrenia, that natural connection is sometimes missing. Their facial expression can be unchanging and mask-like. Their voice may be monotonous. They make few gestures. Eye contact is poor. And sometimes, when people with schizophrenia do express an emotion, it doesn't match the situation. They'll laugh at bad news or appear disappointed when receiving good news.

Reductions in speech – The technical term for this is "alogia" although it's usually referred to as "poverty of speech". People with alogia will answer questions with very brief responses. They may hardly speak at all. Their speech may be interrupted by long pauses. Or they may suddenly stop speaking in the middle of a sentence and be unable to recall what they were going to say. The ability to engage in casual conversation may be completely lost.

Impaired attention – Difficulty staying focused during conversations and an inability to concentrate even on simple tasks. Sometimes this is caused by A/H – voices that distract the person's attention – but the problem still exists even when people aren’t hearing voices.

What causes schizophrenia?

Schizophrenia isn't caused by drug use. It isn't because of something the person did or how their parents raised them. It's caused by something that occurs before birth, probably a combination of genes that can be passed from generation to generation. It tends to run in families. Studies done with identical twins, who share the same genes, have found that if one twin develops schizophrenia, the other twin is likely to develop it too -- even if they were separated at birth, grew up with different families, and never met each other.

The illness is believed to change the levels of 2 chemicals we all have in our brains -- dopamine and serotonin. When a person takes medications that change the levels of these chemicals (most often by blocking dopamine receptors) the severity of some of their symptoms, especially the positive ones, can be reduced. But relief only lasts as long as the person takes their medications, so if they stop, the symptoms come back.

What should I do when a client has this diagnosis?

Don't allow all your interactions to center around their illness. Get to know them. Find out what their interests are. Have casual conversations with them. Listen to them. Laugh with them. Talk about life. Remember that they're a real person just like you. Their illness is only a small part of who they are.

Sometimes their symptoms will be well-controlled and you won't even know they have an illness. If they have a co-occurring disorder, you may be focused on that instead. But if you do recognize some of the symptoms above, below are some ideas on how to handle them.

Delusions and paranoia - The client tells you something bizarre you know isn't true -- for example, that God has sent them on a mission to save the world and evil people are trying to stop them.

Understand that when someone has a delusion, they're absolutely convinced it's true. No amount of evidence will change their mind. If you argue with them and try to prove them wrong, you can wind up getting incorporated into their delusion. The client may decide you're one of the evil people who's after them. Once a client gets an idea like this in their mind, it can be hard to work with them.

But at the same time, you don't want to agree with everything they say. You don't want to lie to them, and you don't want to reinforce a false belief you know is already causing problems. So what do you do?

You borrow a skill from DBT -- experiencing things without passing judgment on them. You speak to the client honestly without dismissing their experience. You say things like this:

"That must be really scary for you. Is there anything I can do to help you feel safer?"

"I understand why you don't want to go outside. Would it be easier if I went with you?"

You're validating what the client feels without passing judgment on what they believe. You probably already do this when clients share their religious beliefs with you.

Surprisingly, clients will rarely put you on the spot by asking if you actually believe their delusion. But if they do, just continue validating how they feel:

"Well, I can see you're really anxious about it. There's no doubt about that. I believe you when you say you're scared."

You might also suggest that clients identify a person or persons whose judgment they trust, who they can share their concerns with and get honest feedback from. These persons can be used to test the validity of distressing ideas clients have and can help them challenge negative things they hear their voices saying about them.  

Auditory hallucinations (A/H) - How can you tell when a client is hearing things? If you ask respectfully, sometimes they'll just tell you. As with delusions, don't dismiss their experience. You may not hear the voices, but your clients do. They can hear them just as clearly as you hear the people around you right now. And more often than not, voices say things that are insulting or upsetting.

Again, just keep it real:

"It must be really upsetting to hear those voices."

"It must be hard to have conversations with everything you're hearing."

"That sounds so confusing and stressful."

But sometimes they won't tell you, and you'll have to rely on things you see. When clients are hearing voices, they'll often seem distracted, as if they're listening to a radio and trying to have a conversation at the same time. They'll stop talking halfway through a sentence, or laugh for no reason. If their voices are loud enough, clients may not be responsive to you at all. You can try repeating what you've said, but don't shout. Give them time to express themselves in their own way. Resist the temptation to rush the conversation forward.

Here are some other things to consider:

1. Most clients who hear voices have already learned about distraction techniques, such as wearing headphones and listening to music. This is the most common way clients cope with voices that are too loud to be ignored. They almost always help, but since they require listening to music or other distracting sounds, they limit what clients can do while using them.

2. If too many people are talking at once, voices can get louder and more distracting. It can be hard for clients to distinguish between the voices of people in the room and the voices in their head. The problem is even worse if the TV or loud music is playing in the background. If possible, try to have conversations 1:1 in a quiet part of the house, with minimal distractions, in a place where you aren't likely to be interrupted.

3. Encourage clients to approach treatment with a plan and stick to it long enough to see if it works. Taking medications at random times, starting and stopping them on their own, and adding other substances to the mix makes it nearly impossible to tell which medications are helping and which aren't. Knowledge is power, and sticking to a game plan is how clients acquire it.

4. If you feel the client is open to it, educate them on the effects of stress. High levels of stress are believed to trigger schizophrenic episodes by increasing the body’s production of the hormone cortisol. Reducing stress is one of the best things a person can do, on their own, to reduce the frequency and intensity of the voices they hear.

5. Exercise can help reduce stress. If you think the client is up to it, suggest they try to for 30 minutes of activity most days, either all at once or broken up into three 10-minute sessions.

6. You can also discuss the importance of getting enough sleep. Lack of sleep can cause hallucinations, paranoia, and delusions even in people who aren’t diagnosed with schizophrenia. To improve sleep, clients should exercise in the morning or afternoon, so that their body’s internal thermostat will be returning to normal around bedtime, triggering feelings of drowsiness.

7. Because sleep is so important, you might also want to educate clients on the effects of commonly used substances. Caffeine affects people in different ways. Some people are sensitive to it while others aren't. Drinking coffee only in the morning, and reducing the total number of cups they drink, may help clients sleep better. Alcohol, if consumed within 4 hours of bedtime, usually makes it easier to fall asleep but harder to stay asleep. Nicotine does appear to provide short-term relief from some symptoms of schizophrenia, but it also stimulates the release of adrenalin, which constricts blood vessels and increases heart rate. This effect persists for 30-60 minutes after smoking a cigarette. If clients are having trouble sleeping, suggest they avoid smoking within 2 hours of bedtime and not smoke if they wake up during the night.

What should I do if a client's symptoms get really bad?

Give them plenty of space

Avoid touching them without asking first

Speak in a calm, quiet voice

Keep any directions simple, clear, and easy to follow

Narrate your actions:

"I'm going to make a phone call now."

"Is it alright if I come sit next to you?"

Call for help if you think anyone is in danger