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Ask the Doctor: Schizophrenia

Why does schizophrenia usually develop in young adulthood?

We are still working to learn more about this crucial aspect of schizophrenia. The current thinking is that changes in brain structure and function are likely present earlier in life, but become evident when they come "online" as the brain matures. Changes in frontal lobes, key neurochemicals (e.g. dopamine and glutamate) and aspects of brain function (such as executive functioning and working memory) are observed in research studies. Young adulthood also is a stressful time physiologically and socially and these stresses may contribute to the onset of the condition. Experimentation with drugs which is common in this age group; research has shown that marijuana likely increases risk of onset.

The American Psychiatric Association is studying the possibility that an earlier diagnosis of people at risk of schizophrenia can be reliably made in DSM 5 due in 2013.

Earlier detection and intervention is an area of increasing interest in the field. Studies have shown that providing support and psychoeduction can help in the early risk period, and a recent European study has shown that Omega-3 fatty acids may be a helpful preventive in young adults at risk for schizophrenia. Similarly, the NIMH funded RAISE study is looking at what helps people right after their initial episode of psychosis.

Is it possible for my brother to live a normal life now that he has this diagnosis?

Schizophrenia is a challenging and complex condition. Symptoms of the condition can be daunting and impact many areas of life, including identity, work and relationships. Long term studies of individuals living with schizophrenia demonstrate that many people who live with schizophrenia adapt to these challenges and do well over time. While every person is unique, engaging in recovery frequently requires a combination of family support, medication, work or school and peer connection. For symptoms that medication doesn't fully address, cognitive behavior therapy (CBT) can make a difference. NAMI is a community where you and your brother are never alone and offers education, support and ways for you to advocate to improve the service system. Many NAMI members have a full life while living with schizophrenia and would love to support you and your family in this process. NAMI's Family-to-Family program was recently found in a randomized controlled study to help many aspects of coping for families.

How can I learn how to engage in my recovery?

A great question! Interest has grown in moving forward in life while living with an illness like schizophrenia. One first principle is to not be defined by the illness or its symptoms, but rather to have your experience of living with it one part of your sense of self. Another principle is to gain wisdom and community from peers who have been there. NAMI's Peer-to-Peer program is a great place to start. The Wellness Recovery Action Program (WRAP) is an established program to engage in this journey. A research base underlies the usefulness of Dartmouth's Illness Management and Recovery Program. Investigating these different choices that can help your recovery is a key step in the journey.

I heard that people living with schizophrenia can work as peer mentors. What does that mean?

The peer movement is strong and growing. Peer support-learning from someone who has been there-is an important and powerful resource. NAMI Connection peer support groups are offered in hundreds of communities across the country through many NAMI Affiliates. Peer support is also a career path for individuals drawn to teaching and sharing their experience. By taking the lessons of living with schizophrenia and offering to help others in their journey, peers provide unique perspective on recovery. Peers mentors are increasingly found in traditional settings such as outreach, assertive community, hospital and emergency rooms. Clubhouses and recovery learning centers offer powerful peer support and leadership opportunities. NAMI is the largest organization of peers living with psychiatric illnesses. You are welcome to join us!

How can I get help for my schizophrenia and my alcohol addiction? The systems don't seem to get it!

Having two conditions makes recovery a greater challenge, yet some common themes emerge in how to manage them both. Learning how to understand your triggers to use of substances is essential to a recovery process. Similarly, learning how to identify and use supports (people, sponsors and medications, community) to help manage symptoms will serve you well. Learning if "self medication" with substances to change how you feel is a vulnerability you have is also important. NAMI's Hearts & Minds online resource offers more information and tips for better understanding and addressing alcohol and drug addiction.

The two systems of care, mental health and substance abuse, have different histories and cultures and this has frustrated many along the way. Currently, efforts are underway to integrate these two cultures and service systems. See information on the Concentrated, Continuous, Integrated Systems of Care model (CCISC) to learn more about efforts to do so one state initiative at a time.

Dual recovery (also called double trouble) groups may be useful for you, though some prefer traditional 12-step programs like AA or NA. Smart Recovery is another option for those who are not drawn to a higher power model of recovery.

Evidence is building that use of marijuana may make schizophrenia more likely to develop and may worsen its intensity. Attention to substance use and it impact on the brain will continue to grow as we learn more about the neuroscience of schizophrenia.

I heard that schizophrenia makes me have a split personality? Is this true?

No. The term schizophrenia was coined by Eugene Bleuler in 1911. He was interested in the mismatch of feelings and thoughts that is sometimes seen in the condition. (Schiz is split, phrenos brain, or minded). This mismatch is sometimes seen but is not a universal element of the disorder. The common confusion with "split personality" (now called Dissociative Identity Disorder) is inaccurate.

Once people hear I have schizophrenia, they pull away and stop seeing me for who I am.

You are not alone in this experience. In a 2008 NAMI survey report, Public Attitudes, Personal Needs, 96 percent of people living with schizophrenia reported they experienced some kind of prejudice or discrimination. This adds an additional challenge to living with the condition. Finding support and a community where you are known for all of who you are makes a huge difference. Selecting opportunities to share your experience can help to move these attitudes forward. NAMI can be a great place to start that journey; the In Our Own Voice Program is a great resource to move these attitudes forward.

I heard suicide is a big problem with schizophrenia. I don't want to lose my son to suicide.

Schizophrenia raises the risk for suicide and estimates are that over a lifetime, about 10 percent of people with the disorder will take their own lives. This is much higher percentage than in the general population and is consistent with the other serious psychiatric illnesses. The risk of suicide is raised for individuals who have co-occurring substance abuse disorders. Clozapine is the only FDA -approved antipsychotic to reduce suicide in individuals with schizophrenia and was shown is a randomized trial to have fewer suicides than olanzapine (another atypical antipsychotic). No other antipsychotic medication has been shown to reduce suicidal outcome in the condition. We know that supportive relationships, community, love, a sense of purpose (e.g. as a peer teacher, working part time) sobriety and belief in a higher power all correlate with reduced risk of suicide.

I heard schizophrenia can cause health problems and even shorten my life. What is that about and what can I do about it?

Every person's health picture is unique and needs attention. We do know that there are risks in some people with schizophrenia that can cause heart disease. Preventing cardiac risk for people living with schizophrenia is important and tips on this can be found at the NAMI Hearts & Minds online resource. For example, smoking is a common health risk in schizophrenia, and weight gain and diabetes are risks associated with many of the antipsychotic medications. Staying active and working to prevent these risks and getting good medical care is important to your quantity of life as well as its quality.

My sister cannot understand that her paranoid thoughts and voices are not real. What do I do?

Lack of insight or awareness into the disorder is common (occurring in about one-half of people living with schizophrenia) and is very challenging for those who love the person. Anosognosia is the medical term for this lack of insight. This is not psychological denial-it is a part of the neurologic makeup for many, and often leads to disengagement from services or medication. Get support to engage your family member. Experience shows that finding common goals-for example, interest in a relationship or a job, is often the best place to start engaging a person. Some service systems have outreach workers who will come to see your sister and listen to her goals and experience. Arguing over whether her experience of reality is accurate to others is often fraught with frustration. See NAMI's fact sheet on Lack of Insight. See also Xavier Amador, Ph.D.'s book, I Am Not Sick, I Don't Need Help.

My brother is unaware that he is sick and is homeless and obviously suffering. Can I force him into getting treatment?

This situation can be a painful dilemma for families. The ability of a state or family to require services is variable and varies from state to state and typically requires demonstration of risk of harm. For example, more than 40 states have assisted outpatient treatment (also called AOT or outpatient commitment) but these are not always enforced and exist in an underfunded service system. The states that allow AOT have safeguards to prevent abuse of this restriction of personal autonomy. Typically, a doctor has to present compelling evidence that the person is dangerous to self or others, and refusing treatment. A judge or a panel of professionals weighs the evidence and makes a determination. The Treatment Advocacy Center lists state-by-state laws on this challenging area of caring for a person living with schizophrenia.

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