So have you ever passed one of those homeless people on the street, and thought to yourself, why doesn't he just get a job? Why doesn't he just, like, this can't be a good way to live. The person seems fit and able. Surely they could find some sort of job. Surely they could find a home of some sort. Anything must be better than living on the street. Well, a lot of those people you see on the street actually suffer from schizophrenia. in fact, it's a very, very common disorder, and one that's really hard to treat and kind of hard for society to handle. In fact, I don't think we've really got a good handle on how to best help not only the people with schizophrenia, but their family and caregivers as well. so let's talk about schizophrenia a bit today. and hopefully you'll leave with a, a better understanding of the complexity of the disorder and the complexity of how to handle the disorder well. Let's do it. Alright, so, Week Seven, Lecture Four. Schizophrenia. First of all, the term schizophrenia means split mind. but I always like to start by saying it does not imply multiple personalities. So we talked about multiple personality disorder. Schizophrenics typically do not have that. They do not change from one personality to another. what they do have, though, is distortions of thought, distortions of perception and emotion, bizarre behavior and social withdrawal. And I want to highlight, oops, I want to highlight here that it, that it says a group of psychological disorders. Because one of the challenges of schizophrenia is that the actual symptoms that a patient shows can be quite different. You can have two schizophrenics in front of you, and they could seem to you like they're suffering from very different disorders. and so it really depends how these symptoms combine, and ultimately we have different sub-types of schizophrenias we'll talk about. That's part of the challenge. It doesn't seem to be, you know, a single thing. Or it at least seems, if it is a single thing, it's a very complex thing that produces these sorts of disordered thinking, perception, emotion and behavior. So it is prevalent, by the way. this is a, you know, an important point to make. If you compare it with various other diseases, even, say, something like Alzheimer's, just about every one of us knows someone touched by Alzheimer's disease. Well, schizophrenia is about twice as prevalent as Alzheimer's disease. So in a sense, we probably know somebody touched by schizophrenia. We may not realize so much that we know people touched by schizophrenia, because it's kept a lot more quiet. There's this notion that, you know, somehow if you have a schizophrenic member in your family, that's embarrassing, or, or there's a stigma associated with it. Let alone if you yourself are diagnosed with schizophrenia. so that's part of the problem with the disease too. Because it's so kind of mysterious and, and hard to really effectively handle, it gets a lot of stigma associated with it. let's talk first now about when schizophrenia tends to hit, and this graph plots, let's just look at the purple bars for a moment. This plots different ages, and how likely it is that a person will be hospitalized with schizophrenia at that age. So for example, the purple bars are, are males, and you see that yes, there's some hospitalized if they're very young, the sort of ten to 14. But really, it seems like the disease really hits late in teen life, and especially in the 20s and 30s, for males. It can, it can strike anywhere through, you know, even up to 90s, 90 year olds, people are suddenly showing schizophrenic symptoms. But most commonly is around here. you know, the sort of mid life, 20 to, 20 to 40 is when men seem to really show the symptoms, or when the symptoms emerge. For women, first of all, it's not as prevalent, especially early in life. And it rises a little later, and it hits more in the 40s to 50s. I'm sorry. My mouse does that every now and. More in the 40s and 50s, it hits, and then tails off. But in later years, it's actually more common for women to, to get it, as they age, than it is for males. So, you know, this interesting distinction with gender with relation to schizophrenia. But again, it's pretty common. it's happening quite a bit. What is it? Well, in the grand scheme, we can think of schizophrenia as encompassing both what are called positive symptoms and negative symptoms. What we mean by positive and negative, positive will be, these are things the schizophrenic experiences that most of us don't. So kind of like additional, or, you know. It's not positive as in good, but positive as in something added to their experience that we don't have. The negative is something missing from their experience that we have. So let's talk about the positive first. And I think they're all kind of related, in a way, to a theme, but you can see the way it plays out for an individual could be quite different. So first of all, the predominant symptom is hallucinations. And especially auditory hallucinations. So they hear voices, is what they usually report, and they hear these voices as though they were coming from real individuals around them. Now, they know they aren't. They, they can see that nobody's speaking with them, and yet, it seems to them like somebody is. It seems to them like someone's right in the room talking to them. 'Kay, really kind of fascinating in a way. so we all hear these voices, but we're able to tell the difference between what's in our head and what's in the real world. They're not. and you can imagine that would be kind of freaky, in a weird way. Now, it's, there's the voices and there's more than that. They have these thought disorders that are also sort of related. It's kind of like they think things and have these fantasies, but again, for you or I, we do that too. but we're able to discriminate our internal fantasies from the external events of the world. They have trouble doing that, so for example, they will, some will have delusions of persecution. They will feel like people are out to get them. So you might feel like this every now and then, a little bit. You might, like, go on a trip somewhere into the city, and you see people with cell phones all away, all around, and you might think wow, it seems kind of like someone's taking a, a picture of me. Maybe. But we tend to have those little fleeting feelings, whereas a schizophrenic might keep seeing these people, and might form this grandiose story that they are all part of some network that's watching me, waiting for me to do something. And maybe they're going to come down and get me at some point in time. So they see these things. They connect them into some sort of internal fantasy. But then they believe this fantasy as if it were things they've actually experienced. I've seen these people conspiring, I know what they're up to in the background. So again, they can't discriminate that internal fantasy from the external reality. Other forms of delusions include delusions of control, where the person might feel that the voice isn't just speaking to them, but it can actually control them in some way. Now, you would think these things are horrible, and often they are kind of viewed as horrible by some. but here's another delusion that can sneak in there sometimes, which is a delusion of grandeur, a feeling like you are a very important person. maybe an important historical figure, or maybe just an important person more generally. So, for example, how do you interpret these voices? Some people interpret them as like aliens speaking to them. Some people interpret them as angels speaking to them. And those on the angel front could, could convince themselves, wow, I have a really important job to do of some sort. The angels have chosen me. I've been, I've been chosen. I am a chosen one. I am important. I have some important role to play. That's this delusions of grandeur. in fact, some people actually think, I am Jesus Christ. I am the next coming of Jesus Christ. Or I am Napoleon reincarnated, or something like that. So they sometimes actually can steal from history, as it were, and see themselves as these really important people. So for some, and this is an important aspect of schizophrenia to consider. You know, this could all sound terrible, or bad in a way, but to a schizophrenic, they often feel like they're seeing things other people aren't seeing. They're understanding things other people aren't understanding. They almost feel more intelligent than other people, and that can be why it's problematic what for them to keep on medications, because the medications that we have for schizophrenia eliminate all this. They can wipe out the positive symptoms. Which in a way is kind of good. The person stops hearing the hallucinations, they stop feeling this disordered thought, but they also feel kind of dumb. They feel like they no longer see these connections that they used to see. And you combine that with side effects, and sometimes they decide, I'm not going to take these drugs anymore. I prefer to be this person who sees things. And of course, as a caregiver, you can't be sure that the person you're caring for is or is not taking their meds. and so that's one of the complexities of schizophrenia, is that, you know, while these disordered thoughts can cause all sorts of problems, even to the point where some schizophrenics, most schizophrenics are completely harmless. But some have killed others thinking they are working for God, the angels have told them to kill some demons. And they do it. and they feel justified in doing it. And, you know, that's an extreme case, but it shows how this can be very dangerous to society in those extreme cases. And yet, the person feels special, feels important, and the drugs, the medications take that away. Something to think about. Now, even when the drugs do handle this, they don't tend to handle the negative symptoms. 'Kay? The negative symptoms tend to remain. What are the negative symptoms? Well again, these are things that these patients lack. That, that mo, that we generally have. So the first is organized speech. So, so, a schizophrenic will often show disorganized speech patterns. They will say things, but what they say doesn't really make sense. So think of that schizophrenic walking down the street in the city, mumbling things, or maybe saying things loudly, and you listen to them for a while. They often have an intensity to them. and so it sounds like what they're saying is really important, but when you listen to it, it just doesn't make sense. It's, it's rambling. and you know, that's one aspect. I mention the intensity schizophrenics are often intense, or can be intense. But they're not usually appropriately emotional. They don't usually get happy about the things that make others happy. Nor do they get sad about the things that make others sad. They tend to be pretty even keel, but again sometimes with this urgency or this intensity. But that's about the most extreme emotionality you sometimes see from a schizophrenic. They tend to lack energy. They don't want to do a whole lot. and they tend to be socially inept. They have an inability to make and keep friends. So let's go back to this homeless guy on the street. let's imagine that he suffers from schizophrenia, and maybe even that he is on medication. So the positive symptoms are gone, he's not hearing the voices in his head, he's not having these delusions, why doesn't he go get a job? Doesn't have any energy, socially inept, inappropriately emotional, and cannot communicate well. Do you want to hire him? Do you want him working for your company? What sort of job do you give somebody like this? you know, this is one of the reasons they have a lot of trouble holding a job. and they can live on the street, which we would find horrible, but they don't seem to find it so horrible. If they can sit on a street corner and not have to talk to people too much, then it's an existence. And it's an existence that many of them gravitate to. They don't have a lot of options so that's one option. Okay, we have the positive symptoms, we have the negative symptoms, now let's talk about how they combine to create some of these types of schizophrenia. Now already, I want to warn you that I'm going to talk about these types as if they were kind of clean, but they're not. they are, they're more, you know, there would be some very clean paranoid schizophrenics. And what, by clean I mean the dominant system would be delusions of persecution. So these are the ones that feel like people are out to get them. and so it's this disordered thought. They might be hearing the voices warning them about stuff like that. so they have auditory hallucinations, so it's these positive symptoms that are really strong in these people. but their intellectual functioning and their emotional functioning might be relatively intact, so they're not showing so many of the negative symptoms, they are really showing the positive symptoms much more extremely. And this is good, because like I told you, our antipsychotic drugs can deal with the positive symptoms. So if these people get on meds, sometimes they, they can live relatively normal lives, as long as they stay on their meds. Again, they tend to feel dumb, and their meds have all sorts of side effects including, for example, sexual side effects, or I should say anti-sexual side effects. Side effects that make it difficult to be sexually active. Some people find that annoying. so you know, there's, there's a bunch of reasons why they will stay, why they will stop taking their meds. and so even though we can treat them well, they stop taking their meds and all this comes back, okay? Disorganized schizophrenic is more heavily weighted on the negative symptoms than the positives. So they have the disorganized speechu disorganized behavior, flat, inappropriate affect. That's the emotionality. That's what's prominent. These people are harder for us to help because the drugs we have, again, do not do much for these negative symptoms. They don't change this and so, yeah, this is a difficult category. But again, keep in mind this is, like, predominantly positive, predominantly negative. there is in fact a situation where there's a little of both going on many situations between these. That's what I mean by, you know, don't assume everyone will fall neatly into this, or this group. There's this third group that's kind of odd. I, I always wonder how it kind of fits, but it's called catatonic schizophrenia, and these are people who show really odd motor behaviors. Sometimes, for example, they will pose, they will stop somewhere, and they will adopt some posture for hours on end, without moving, where if you or I try to do that we'd feel horribly uncomfortable. But they seem to just sit there. In fact, you can take them and move them around, and pose them. And they will hold the pose, and sit there for a long period of time. Really odd so this seems to be a class almost in and of itself. sitting there. Now undifferentiated, this is, this is the nice little garbage can. Well, you know, if you don't fall cleanly here, or cleanly here, or cleanly here. We call you undifferentiated, which means, heck, we're not really sure. it's some other mixture of these, these things. so, you know, that can add to the complexity of treatment. Now we also, these are other terms that are used with schizophrenics that aren't really types, but they kind of are. So let me, let me just explain these. We'll talk to somebody as being a residual schizophrenic, if they let's say, are undifferentiated, so they have some mix of positive and negative. We now give them antipsychotic drugs, so the positive symptoms disappear. And they're left, you know, probably sort of like some level of disorganized, but we call whatever's left residual. So it's a residual schizophrenic. So that their main symptoms are being treated but they still have some left over symptoms, some residual. and then we will sometimes make a distinction between how the symptoms emerge. A reactive schizophrenic, the symptoms emerge suddenly. They, they onset really quickly and usually related to some stress in the, in life. And the good news about that is that sometimes if, if that individual can deal with the stress, or if people can help them deal with the stress, the symptoms may subside. When the stress does. So it's, it's the symptoms are literally reacting to some stress. Which means we have a lever, maybe, to pull 'em back. Versus, process schizophrenics. For process schizophrenics, whatever symptomology they show just generally builds, and builds, and builds, and gets worse, and worse, and worse, and worse over time. That's not good. those sym, those patients have the poorest diagnosis or the poorest prognosis. Harder to treat those sort of patients. They just continually get deeper and deeper into the schizophrenic landscape. So, so we'll sometimes draw those distinctions, as well. You know, you get a sense from this slide. Lots of labels, lots of categories, lots of sort of subtypes of things, that's what makes schizophrenia so, so challenging. so hard to deal with. There certainly is a genetic link as well. So what this is showing is how much at risk are you of getting schizophrenia if let's say your parents are schizophrenic. So, so someone whose parents are schizophrenic has a risk. If your children are schizophrenic, you have a little more risk. I think this is the parents of a schizophrenic. The children of a schizophrenic. These are the children if both parents are schizophrenic. Very high. So you're up to 40% if you're, if you're a child of two schizophrenic parents. You have a 40% chance. If one of your brothers or sisters are schizophrenic again, lesser chance. Basically the idea here. Look at this one, by the way, this one's really important. If you have an identical twin and your identical twin is schizophrenic, there's a 60% chance, almost, that you will be. So these are all the sort of direct relatives, first degree relatives. If you go a little further, if you have uncles and aunts or nieces or nephews or grandchildren or half brothers that are schizophrenic then, you know, there's still a risk but it's not anywhere like these purple bars. So the real point of this graph is there's something about kin, there's something about family, there's something about shared genetics that increases your risk of schizophrenia. and so clearly, some sort of biological process is at play here that, that's, that's helping this disease along and that is underlying it. So at least you know, at some point, sometimes that's hopeful, because the notion is, or the hope is that some biological treatment might help us help these people. We're not really there yet. Not all that well, anyway. all right, so here's some follow up things. There's all sorts of things you can find about schizophrenia online. here, but here are the ones I'm highlighting. So first of all, ABC has a 20-20 episode on schizophrenia. This is part 1. There's a part 2. You'll see a number of other documentaries on YouTube that, that are really useful for walking you through. This is a shorter video that just highlights for schizophrenic patients. So it's good to actually kind of, you know, get to see a schizophrenic patient and get a sense of what their behavior is. and although uncommon, schizophrenia does affect children at times. That can be very troubling. And so this is a short video about, about that, childhood schizophrenia. the reading side. The first thing I have here is a information booklet that's put out, aimed at family and caregivers of schizophrenic, phrenics. They often, family members can find it so hard, it's, it's really difficult to know how to help a schizophrenic relative. you know, someimes the only way to get them help is, they have to commit a crime first, in, in order to, you know, get the criminal system working and, and watching them, and helping a family caregiver to actually control them. But if they haven't done that, the hospitals often treat them right away and then give them back to family members. And then if they're not staying on their meds and, and doing things like that, it's really, its really hard. It's, it's so anyway, this is meant to give you some tips if you're in that situation. This is just an overview of schizophrenia, to give you a sense of the signs, the types, and the causes, so this is just a good complement to what I've talked about today. And then finally, this is kind of an interesting one I thought you might want to check out. These are some new studies that suggest that, well, let me say it this way. We know that patients with schizophrenia show odd eye movements. They don't move their eyes the same way we do. And so now, the claim is, maybe you can diagnose schizophrenia by looking at eye movements. And, and some of these claims say we can diagnose it with 100% accuracy. So I like this description, because it describes that, but it also describes the science behind that. So a good one for you to check out and get a sense of the scientific process. And, you know, get, get I guess, a heads up towards some new diagnostic techniques that really are an interesting complement to the DSM kind of process that I told you about. So kind of think about that when you check it all out. All right, so that's schizophrenia. I hope you found that educational. And for those of you who are helping someone with schizophrenia or suffering from it yourself you know, I, I really hope this was helpful to you. Thank you, I will see you next time. Bye bye.