Schizophrenia

People with schizophrenia experience acute psychoses, phases in which their perception of reality is often very distorted.

For example, they may hear voices or think they are being followed or influenced by other people. Their behavior also changes: many people stop speaking coherently and some become almost completely detached from reality.

Acute psychoses are usually temporary and some people only experience such phases once or a few times. Others have the symptoms permanently, in which case they need a lot of support.

Schizophrenia means “split mind”. However, this often leads to the misconception that someone with schizophrenia has a “split personality”.

This mistaken view increases prejudices against people with schizophrenia. This is because they can have phases involving a severely altered perception of reality and different behavior but their personality does not change, i.e. is not split.

Schizophrenia also has a wide range of symptoms, causes and progression.

A distinction is made between various types of schizophrenia, based on typical symptoms. The most common forms are as follows:

Paranoid schizophrenia

People with this kind of schizophrenia have delusions and hallucinations. For example, they hear voices or think they are being watched and influenced by other people. This is the most common type. It usually begins between the ages of 25 and 35.

Residual schizophrenia

People with this form of schizophrenia have chronic symptoms that mostly occur after an acute psychotic phase. They become very passive, lethargic and appear depressed. They may also have difficulty concentrating or experience memory problems.

Disorganized (hebephrenic) schizophrenia

This type is characterized by an abnormal emotional life with a mood that barely changes and is often inappropriate to the situation, as well as erratic thinking and inappropriate behavior. Disorganized (hebephrenic) schizophrenia usually begins between the ages of 15 and 25.

Catatonic schizophrenia

This is a very rare form of the illness that affects the way people move. For example, they may become hyperactive for no reason, remain completely immobile or pull faces. This form also usually begins between the ages of 15 and 25.

In many cases, indications of an acute psychotic phase or episode occur well in advance. People with schizophrenia and, in most cases, those close to them notice a change in the weeks or months leading up to the episode. This can be in the form of stress, restlessness or sleep problems, concentration problems or memory problems.

Mild hallucinations are also possible. People with schizophrenia can furthermore feel like they are being watched and influenced by other people.

For more detailed information about the symptoms of schizophrenia, please visit gesundheitsinformation.de.

The precise causes of schizophrenia are as yet unknown. The interaction of multiple factors is probably involved.

It is known that some people have a congenital predisposition to schizophrenia, particularly if a parent or sibling already has it.

Around 12 percent of children with a schizophrenic parent also develop the condition.

There may also be other factors involved that increase the likelihood of developing the illness. These include:

• changes to the brain
• insomnia
• drug use, for example of cannabis or amphetamines
• traumatic experiences
• mental stress
• developmental disorders in the womb or in childhood

A psychosis is often associated with major life changes, such as divorce, moving home or starting work.

Schizophrenia is also more likely to occur in a family atmosphere where children are often criticized and constantly told what they can and cannot do.

It is estimated that about 5 in every 1,000 people will develop schizophrenia at some point in life. Men are affected slightly more often than women.

Schizophrenia is most statistically likely among people who are socially disadvantaged and those who are single. However, loss of social status and loneliness are often consequences of the illness itself.

The first acute episode usually occurs between the ages of 15 and 35.

An increase in unexplained symptoms over several years is often an indication of the disease.

Precursors of a psychosis

Potential precursors include depression, moodiness, restlessness, self-doubt, difficulties concentrating or anxiety, for example. In many cases, there are unexpected problems at school or in college.

Many people in the early stages of schizophrenia neglect their appearance or withdraw from their social environment.

Prevalence of psychoses and consequences

On average, the first acute psychotic episode occurs a few years earlier in men than in women. The reason for this is unknown. Schizophrenia very rarely starts in childhood.

Around a quarter of people with schizophrenia only ever experience a single acute psychotic episode. Around 60 out of every 100 have a relapse within two years of their first acute psychotic episode. It can take weeks or months for an acute psychosis to subside.

People often continue to experience the effects of an episode of psychosis for a long time, even if they have no symptoms. What they have experienced can unsettle them and affect their feeling of self-worth.

However, some are able to easily return to their daily routine and live a normal life after a psychotic phase. Others are permanently affected and need intensive support.

Impact on life expectancy

On average, people with schizophrenia die around 15 years earlier than the rest of the population.

In particular, life expectancy is lower for those who have frequent relapses. There are many reasons for this. For example, it is more common for them to have addictions and consume more alcohol, nicotine and drugs. They are also more likely to have infections, heart disease or diabetes.

These types of physical conditions may be due to their lifestyle or side effects of anti-psychotic medication.

If schizophrenia is treated properly, life expectancy rises.

Around 5 percent of people with schizophrenia take their own life. This is more common in young men who have their first acute psychotic episode or people who have had a severe form of the illness for a long time. Critical periods are untreated psychotic phases and the period immediately following discharge from hospital.

Schizophrenia is only diagnosed if the typical symptoms have been present for more than a month.

More weight is given to symptoms such as delusions or persistently hearing voices.

Less weight is given to symptoms such as confused speech, unexplained hyperactivity or hallucinations other than hearing voices. This is because these symptoms are less typical of schizophrenia.

To determine if someone is truly experiencing schizophrenia, doctors will talk to both the person affected and their relatives and observe the person’s behavior.

Physical and neurological examinations are performed to rule out other potential causes of the symptoms.

Similar symptoms may be caused, for example, by disorders of the nervous system or alcohol and drug abuse.

Certain symptoms of schizophrenia can also occur under the influence of drugs or in people with other conditions such as depression or anxiety disorders.

All of this means that a careful examination by a specialized psychiatrist is a very important part of the diagnostic process.

The treatment of a person with schizophrenia should primarily be centered around their needs. However, this is only possible to a limited extent if they are experiencing their first acute psychotic episode.

Designing and planning treatment with the patient based on their individual needs is more likely to succeed once the acute psychosis has subsided.

Providing fast, effective treatment increases the chances of a positive outlook for schizophrenia.

Treatment and support options

There are various treatment and support options for schizophrenia:

• Support from the person’s social environment: Family, friends and acquaintances can provide emotional support, be helpful during everyday life and give the person more stability.
• Medication: Anti-psychotic medication can help resolve acute symptoms and make relapses less likely in the long term. However, medication can have distressing side effects.
• Psychotherapy: This can reduce symptoms and help the person to better manage the illness. Common forms include cognitive behavioral therapy and family therapy. Psychotherapy can be helpful in all phases of the disease, even during an acute psychosis.
• Psychoeducation: This involves training people with schizophrenia and their loved ones in key aspects of the symptoms, treatment and management of the disease. Psychoeducation also provides an opportunity to share experiences with other people who have schizophrenia.
• Sociotherapy: This can help people reconnect with their professional and social lives and to live as independently as possible. Sociotherapy can sometimes also alleviate the symptoms.

Further information on treating schizophrenia with medication as well as on psychotherapy and psychosocial support for schizophrenia can be found at gesundheitsinformation.de.

Inpatient treatment for acute psychosis

People with schizophrenia may receive inpatient or outpatient care. Treatment is often provided in a psychiatric hospital during an acute phase. People affected by schizophrenia often do not realize that they are experiencing an acute psychosis and may refuse treatment.

This can result in compulsory admission to a psychiatric hospital. However, this is only legally possible if someone is at an acute risk to themself or others, for example due to suicidal thoughts or highly aggressive behavior, and the risk cannot be otherwise eliminated.

Entering into a treatment agreement

People with schizophrenia can enter into a treatment agreement with doctors for situations such as compulsory admission. This may, for example, specify what action is to be taken if they experience an acute psychosis.

This allows agreements on how medication is to be administered and how compulsory admission is to be handled if it cannot be avoided as well as which other types of support are desired.

It may also be advisable to draw up an advance health care directive (“living will”) and a lasting power of attorney for health and welfare to cover this type of situation. This states who is authorized to make decisions if the person affected does not have the capacity to do so.

The first point of contact is usually the family doctor, even in cases of potential schizophrenia or acute psychosis.

The “Telefonseelsorge” crisis hotline provides support to people experiencing acute problems and helps arrange further assistance. Various advisory services are also available for people with schizophrenia.

The Federal Association of Psychotherapists (Bundespsychotherapeutenkammer) provides a therapist search on its website. The appointment service centers of the Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen) help people with schizophrenia make an appointment at a specialist or psychotherapy practice.