Thought Disorders
Mark Vakkur, M.D.
Q: What is a thought disorder?
A: "Thought disorder" is a general term used to describe any of several illnesses or disease processes that disrupt reality-testing and perception, creating symptoms such as delusions or hallucinations. These illnesses include schizophrenia and schizoaffective disorder. Thought disorders are generally differentiated from "mood disorders" which may also sometimes cause psychotic symptoms.
Q: What is schizophrenia?
A: Schizophrenia is a thought disorder that may lead to a profound disturbance in reality-testing (e.g., delusions) or perceptual disturbances (such as hallucinations). There are several types of schizophrenia, such as paranoid, disorganized, and undifferentiated, and a wide variability in symptoms and clinical course.
Q: How rare is schizophrenia?
A: Between 1-3% of the population has schizophrenia. This appears to be true across cultures.
Q: What causes schizophrenia?
A: The exact cause is unknown, but the overwhelming evidence is that schizophrenia is a biological disorder transmitted genetically. Schizophrenia runs in families. 50% of affected identical twins develop the disorder. However, 50% don't, so there appears to be an environmental influence also.
Q: Is schizophrenia caused by bad or inappropriate parenting?
A: No. Sigmund Freud developed a theory of the "schizophrenogenic mother" but little or no empirical evidence supports this idea. There is some evidence, however, that "high expressed emotion" parents may worsen the outcome of schizophrenia offspring.
Q: When do most people develop the symptoms of schizophrenia?
A: In their teens to early 20's. The symptoms of paranoid schizophrenia can develop somewhat later.
Q: Are there any clues that indicate a child is going to develop schizophrenia?
A: Some studies indicate that children who later develop schizophrenia tend to be somewhat more clumsy and form fewer attachments than children who don't. Also, some may have subtle neurological signs. However, most children who are somewhat odd when growing up do NOT develop schizophrenia.
Q: Is there a blood test or some other test to determine if someone is schizophrenic?
A: No; schizophrenia remains a clinical diagnosis, meaning that a mental health professional must take a detailed personal and family history, then perform a mental status exam. Preferably, a patient should be observed over a period of months to years before a diagnosis is made.
Q: What other illnesses may cause symptoms that look like schizophrenia?
A: The list is long, but substance abuse, especially of cocaine, amphetamines, or hallucinogens can create psychotic symptoms. Also, it's important to tease out whether mood symptoms are present, and if so, whether they preceded the thought disorder symptoms. Bipolar disorder, manic depression, and depression can all create psychosis.
Q: Can an experienced mental health worker distinguish between schizophrenia and other illnesses?
A: Not with one mental status exam. Studies indicate that despite the folklore to the contrary, the ability to diagnosis schizophrenia from a single interview (without a past history and family history) is no better than chance.
Q: What is schizoaffective disorder?
A: Schizoaffective disorder is an illness that has both mood symptoms (depression or mania) and thought disorder symptoms, with some thought disorder symptoms in the absence of mood symptoms. The diagnostic criteria are complicated, but the bottom line is that those with schizoaffective disorder straddle the categories of mood disorder and thought disorder.
Q: What are the diagnostic criteria for schizophrenia?
A: You must have at least 2 of several symptoms over a 1 month period (less if treated): delusions, hallucinations, disorganized speech, grossly disorganized behavior or catatonia, or negative symptoms.
Q: Does schizophrenia mean a person has a "split mind"?
A: No, this is a common mistake propagated by the media, who often describe someone who thinks and acts in diametrically opposed ways as "schizophrenic."
Q: What are delusions?
A: Delusions are fixed, false, idiosyncratic beliefs. Fixed means that they are deeply embedded; you can't talk someone out of a delusion. False means that they are demonstrably untrue (such as the belief that someone's brain has been surgically removed and replaced with electrodes); sometimes this is a judgment call and may require third party sources of information (e.g., fear that one's spouse is attempting to kill him or is unfaithful). Idiosyncratic means that the belief is unique to the individual and not part of a larger, widely held cultural belief. The idea here is that delusions would be identified as odd or bizarre by others of the same belief system or culture.
Q: Can you talk someone out of a delusion?
A: No. Delusions by definition are fixed. This is an important concept to remember when dealing with those who suffer from delusions. You cannot "prove" to someone that he is suffering from a delusion.
Q: If someone suffering from a delusion tells me something that I know is "crazy", how should I respond? I know I shouldn't try to talk them out of it, but should I act as though I believe it too?
A: No. Firmly, calmly, and without judgment explain that you do not share that particular belief. If the person is receptive, you might even say that you believe that the other person's mind might be playing tricks on them and that it may be hard for them to see it at the time. If the person grows agitated or angry, try to convey that you respect their point-of-view even if you don't share it. Statements such as "we'll have to agree to disagree" can be helpful.
Q: What is a hallucination?
A: A hallucination is a perceptual disturbance that can take the form of a voice or sound that is not there (auditory hallucination) or a vision of something that others don't see (visual hallucination).
Q: What are negative symptoms?
A: Negative symptoms are the more subtle symptoms of schizophrenia that tend not to respond to older medications, but may respond to some of the newer ones. These symptoms include social withdrawal, flat affect, low motivation, inability to experience joy, and a general flattening of one's personality.
Q: What is thought to be the disease mechanism of schizophrenia?
A: The most likely current explanation is that schizophrenia represents excess activity of dopamine, a neurotransmitter (chemical messenger used in the brain). This idea is probably overly simplistic since dopamine does different things in different parts of the brain, and some of the newer medications have less effect on dopamine than on other neurotransmitters, such as serotonin.
Q: What parts of the brain seem to be affected?
The parts of the brain having to do with mood, judgement, and integration of sensory perception, namely the limbic and frontal cortical regions.
Q: What is the outlook for someone diagnosed with schizophrenia?
A: The long-term clinical course varies widely from individual to individual. Family support, occupational training and rehabilitation, as well as appropriate medication can help people with schizophrenia tremendously.
Q: Can schizophrenia be cured?
A: Schizophrenia is thought of as a life-long disease, such as diabetes, but the symptoms can be reduced tremendously and quality of life improved dramatically with appropriate intervention.
Q: What can I as a family member do to help someone suffering from schizophrenia?
A: First, take care of yourself. Attend to your own emotional response to the diagnosis. To be of maximum benefit, you must deal with your own feelings. Many family members go through tremendous crisis before (and even after) the diagnosis of schizophrenia is made. Taking care of a loved one with active psychosis is a 24-hour-a-day job. You can't do it alone.
Develop a support network in your community. Have a list of friends or family you can call on to help share the burden and problem solve. Be supportive. Be an advocate. Get to know your relative's care team and stay in touch (with your relative's consent). Be realistic in what you can expect. Give your relative space; don't hover. Most of those suffering from schizophrenia need plenty of space, especially when symptoms are flaring up.
Get involved. Help fight to remove the stigma associated with mental illness. Let your elected representatives know how you feel. Get involved in the fight for parity in mental health coverage.
Q: My son or daughter has been diagnosed with schizophrenia. Does this mean he or she will never be able to go to college, have a family, become a grandparent?
A: There are no absolute rules, and nothing should be ruled out, but expectations have to be realistic. The positive symptoms of the illness, which may worsen from time to time even with the best medication regimen, may disrupt school, work, or the formation of a new relationship. The negative symptoms, such as social withdrawal and low motivation, can interfere with these areas also. But a creative approach to problems as they arise, along with realistic, achievable goals, often mean that many individuals with schizophrenia can do many of these things. The most important objective is to maximize quality of life, and to help your son or daughter feel connected and integrated into his or her community.
Q: Is someone with schizophrenia dangerous?
A: Dangerous is a relative term. Most people who commit violent acts are NOT schizophrenic. Those who suffer from schizophrenia have a modestly elevated risk of violence, but this risk is greatly hyped by Hollywood. Most violence in our society is committed by someone with an active substance abuse problem or personality disorder, NOT schizophrenia. Clearly, if someone has a persecutory delusion and is very frightened, his behavior may be influenced by that delusion, so judgment must be used. This is another reason why a team approach (client, family, community support system, and mental health workers) is critical. Reducing general risk factors for violence, especially access to firearms, is always a prudent first step for any family.
Q: What are some resources that can help those who suffer from thought disorders and their families?
A: There are many:
Your mental health providers would be happy to provide you with additional information for everything from medication side effects to support groups.