Let's consider the case of Jason, a fictional patient representing a compilation of several patients I have met over my years of practice.
Jason was 14 when he stopped playing hockey, a game he'd loved all his life. He was smoking pot daily with his friends, but over the next year he became irritable, depressed and withdrawn and his grades plummeted. At 16, Jason dropped out of school, stopped showering, and rarely left his room. He told his brother he was tired of being controlled by everyone and he wanted to move out.
On his 18th birthday, he tearfully told his parents ISIS had been sending him "encrypted messages" and were monitoring his activities. He said he was afraid to leave home because ISIS was planning to kidnap and behead him. Jason admitted he was hearing voices saying, "They're coming." To him, this meant ISIS was closing in and he was in imminent danger. Weeks later, Jason was diagnosed with schizophrenia.
Delusions and auditory hallucinations are hallmarks of schizophrenia.
Schizophrenia is a complex and often devastating illness, characterized by the presence of psychotic symptoms including delusions, hallucinations, disorganized thinking and behaviour and negative symptoms (apathy, lack of motivation, social withdrawal, and reduced emotional responsiveness). Psychotic symptoms are also associated with bipolar disorder, delusional disorder, schizoaffective disorder and sometimes, severe depression.
Schizophrenia steals young, productive lives and shortens life expectancy by up to 25 years. The onset of psychotic symptoms usually occurs in the teens or 20s, but early non-specific symptoms, called a prodrome, may predate psychosis by years. Jason's prodromal symptoms began at age 14 and were typical: social withdrawal, listlessness, depression and unusual, if not yet delusional, thoughts.
Delusions and auditory hallucinations are hallmarks of schizophrenia. Delusions are false but unshakable beliefs, maintained despite indisputable evidence to the contrary. They are often bizarre, like Jason's belief that his dentist had implanted a monitoring device in a filling at the request of ISIS. Schizophrenia-related delusions are most often persecutory or paranoid, reflecting suspicions of malicious intent (someone is trying to cause them harm).
Anosognosia, or lack of insight, is a devastating aspect of all psychotic disorders. Many patients refuse or discontinue treatment because they don't believe there is anything wrong. Jason was devastated and irate when his parents didn't believe ISIS was threatening him and began to wonder if his dad might be part of an ISIS sleeper cell.
Many patients with schizophrenia have disorganized thinking and behaviour.
Jason's auditory hallucinations are typical of schizophrenia: a voice or voices speaking to or about him that are almost always derogatory. They may speak directly to him ("You're an idiot"), speak of him in the third-person ("He shouldn't do that"), or sound like a running commentary ("Jason's eating breakfast"). Rarely the voices command an action ("Hurt yourself"). Visual hallucinations are not usual in schizophrenia but are more often associated with medical conditions or withdrawal from substances like alcohol.
Symptoms of depression and anxiety are common in schizophrenia, which has a high risk of suicide. Up to 40 percent of patients with schizophrenia will attempt and up to 15 percent will complete suicide. Because Jason is male, depressed and anxious and he abuses pot, his risk of suicide is elevated, however, his loving, supportive family and effective treatment can reduce the risk.
Many patients with schizophrenia have disorganized thinking and behaviour. Thoughts can be so disorganized that speech may difficult to follow or completely incoherent. Jason told his doctor, "I know you don't know this, but I know that you'll know when the time is right. They know when to tell us, and it will become clear to you, them, me and the ones we need to know more about. My arm chair is probably the best place to be."
Schizophrenia commonly presents earlier in boys than girls. As a result, girls often attain a higher level of education, have stronger ties to supports networks and have more mature interpersonal skills. A later onset of psychosis can result in valuable socioeconomic benefits: increased suitable, stable employment, greater engagement in treatment, and reduced poverty and homelessness.
There is abundant scientific research demonstrating the long-term impact of schizophrenia on brain structure and function. Brain changes may be evident in the prodromal phase, even before psychotic symptoms have manifest. With each psychotic episode, injury to the brain progresses. Chronic schizophrenia is associated with cognitive deficits that impact thinking speed and organization, mental flexibility, memory and concentration.
These cognitive deficits reflect an underlying brain injury and the severity of cognitive dysfunction is directly correlated with episode frequency and severity. When schizophrenia becomes chronic, the psychotic and cognitive symptoms may not resolve, even with treatment.
Much remains to be understood about what causes schizophrenia and we desperately need better tolerated, more effective treatments.
Schizophrenia treatments are far from perfect, but they tend to be more effective early in the course of illness. While medication tolerability has improved over the last few decades, for many patients accepting treatment remains a major challenge. Early-psychosis programs attempt to engage young patients through education and support to prevent illness progression, but this is challenging in the face of serious treatment side effects, negative beliefs about the need for treatment, lack of adequate mental health resources, and lack of insight.
The cause of schizophrenia is multifactoral. There is a genetic component: identical twins have the same DNA and if one has schizophrenia the other has a 50 per cent risk of developing the disorder. Other factors play a role in causation, impacting brain development before and after birth. During the prenatal period, infections, oxygen deprivation, poor maternal nutrition, cannabis abuse and maternal stress are possible risk factors. Psychological stress and cannabis abuse appear to be the most important environmental factors promoting schizophrenia during childhood brain development.
Schizophrenia is devastating for patients, their families, and society, impacting young lives in their prime and impairing a patient's ability to fully participate in society and meet their personal goals. Much remains to be understood about what causes schizophrenia and we desperately need better tolerated, more effective treatments. Modifiable risk factors, like avoiding pot during critical brain development, strong social supports and good maternal healthcare, may lessen the risk, but more research is urgently needed.
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