Schizophrenia, schizotypy and schizoaffective disorder in adults

Schizophrenia can have several causes. Research shows that biological, psychological and social factors influence whether you develop schizophrenia. However, therefore is no single explanation for why people develop schizophrenia.

Today, schizophrenia is understood in terms of the stress vulnerability model. This means that some people are particularly vulnerable. Therefore, they develop schizophrenia more easily
if they are subject to strains and stress, for example in connection with traumatic events.

There is a greater risk of developing schizophrenia if you are related to someone who also has it. The risk is higher if this is a close relative – for example parents or siblings.

We know that the risk of developing schizophrenia is:

• 1% in the general population;
• 4% in the grandchild of a person with schizophrenia;
• 10% in the siblings of a person with schizophrenia;
• 13% in the children of a person with schizophrenia;
• 46% in children of two parents with schizophrenia.

Several genes are thought to be of importance to the development of the disorder. Depending on which genes you have, you may be more or less susceptible to the disorder.

However, it is not certain that you develop schizophrenia even if you have the genes that entail a risk of developing the disorder. Some strains are generally required before the onset of the disorder.

Before the onset of the disorder, the person has often been exposed to some kind of stress. Stress may be many things. It is not just a question of being too busy.

Stress and strains may be:

• Biological strains

  May occur already in the foetal state if, for example, the mother does not have a sufficiently healthy diet. Lack of oxygen during childbirth may also increase the baby’s risk of developing schizophrenia later on. The major hormonal changes during puberty may also cause the disorder to develop.

• Mental strains

  May, for example, be breaking up with a boyfriend or girlfriend, deaths among close relationships, physical, psychological and sexual abuse.

• Social strains

  May be both positive and negative events. For example taking an exam, starting a new job or moving away from home.
  Such strains are common. You can only develop schizophrenia if you also have a particular susceptibility.

The brain consists of billions of nerve cells. They send signals to each other via neurotransmitters. Changes in brain structure and function can be seen in some people with schizophrenia. Changes in the brain’s neurotransmitter dopamine are thought to be of importance. Other changes in the brain can be seen in some people with schizophrenia. Researchers are still trying to determine the significance of these changes.

The disorder usually develops insidiously. However, it may also have a very sudden onset. Some have experienced difficulties already in childhood. This may, for example, be that they have always had difficulty socialising with others.

The symptoms may be severe and debilitating. But they can also be mild, so that they are hardly noticeable in everyday life.

Some of the symptoms of schizophrenia are:

• Hallucinations
• Delusions
• Language disturbances.

You can read more about these and other disturbances below.

People with psychotic symptoms perceive reality differently than most other people. These are also called positive symptoms because symptoms have occurred that have not been there before. These may, for example, manifest themselves through:

• Hallucinations
• Impact and control experiences
• Delusions.

Hallucinations are when the brain incorrectly perceives a sensory impression that is not actually present. Hallucinations can occur in relation to all the senses:

• Sense of hearing
  For example, many hear sounds or voices talking about them.

• Sense of taste
  Things may, for example, taste rotten or of petrol.

• Sense of sight
  For example, they can see people or things others do not see.

• Sense of smell
  For example, they may experience smelling toxic gas.

• Sense of touch
  They may, for example, experience that someone is touching them.

They may experience that their thoughts can be heard by others. Some also feel that other people can transfer their thoughts to them and that the actions and thoughts from others can be inflicted on them. This gives them a feeling that their actions and thoughts are not their own – but those of others.

People with schizophrenia may have odd little movements. Perhaps they walk on their toes, caress themselves on the head in a certain way or have constantly raised eyebrows. The symptoms used to be more common and severe than they are today.

Delusions are notions that only make sense to the afflicted person. They are not shared by others. Many delusions are characterised by inverted logic. This means that everything confirms the delusion. In a delusion, any experience which would dispel the delusion for other people will serve as evidence that the delusion is real.

Different types of delusions:

• Persecutory delusions
  The most common delusions. This means that you experience being watched and pursued. For example, you may feel that you are being pursued by the CIA because
  you have valuable knowledge.
• Delusions of grandeur
  For example, you can be convinced that you have a mission to save the world.
• Delusions about the body
  You may also have a delusion that your body has changed. Perhaps your head is about
  to fall off, organs are moving around your body, or your body is about to dissolve.
  You may also get a notion that you suffer from serious illnesses.

Many experience a loss of previous abilities. This is also called negative symptoms, because you lose something you were previously able to do. When you lose abilities, you cannot handle the same demands that you could before. This may make it hard to conduct a normal everyday life, including because of a lack of overview and energy.

It is important to remember that these symptoms are not your personality. You are still the same as before the disorder struck.

The experienced symptoms may include:

• Flattening of emotions
  Your emotions become less ‘strong’. For example, it may become difficult to feel joy, sadness and anger.
• Lack of initiative and passivity
  You may have difficulties taking an initiative and getting started with tasks.
  Many schizophrenics find it harder to hold on to interests and have less energy.
• Deterioration of contact
  You may have difficulty understanding and reading other people’s intentions and aims.
• Isolation
  You may start isolating yourself. For example, the idea of giving someone a hug may become unpleasant or downright frightening.
• Doubt/ambivalence
  Opposing thoughts and feelings may arise. This may make it difficult to make decisions. One moment, you may want to go to the cinema – the next, the idea of going to the cinema will seem appalling.

The symptoms are not signs of laziness. They are instead signs of illness.

The way you think and talk may change. Your language may become less expressive, with words and sentences that only make sense to yourself. You may give words a new meaning or create new words that do not exist. Speech can become so jumbled that other people simply cannot understand what is being said.

You may also take what other people say very literally. For example, if somebody says, “I’m dying of laughter!”, you may take that to mean that the person in question is actually dying.

Many schizophrenics also experience that their thoughts are churning around in their heads and that it is difficult to keep hold of them. Others may find that their thoughts suddenly come to a complete standstill.

The assurance we normally have in relation to who we are, who other people are and what the world is like may vanish. For example, the sense of yourself, your identity and your sense of time may change.

75-80% of people suffering from schizophrenia have cognitive problems, including with:

• Attention
  It can be difficult to stay concentrated for an extended period of time. For example, they may have problems going to school. They also become confused more easily.
• Tempo
  They may need longer time to perform everyday tasks.
• Problem solving
  They may have difficulty planning, performing and keeping track of things like cooking, trips and finances.
• Memory
  They may, for example, have problems learning new things and have difficulty remembering appointments.

Symptoms may affect everyday life

All these symptoms may make many things more difficult in everyday life. It may, for example, become difficult to hold onto a job and to be together with other people. Some may find
it difficult to meet even basic needs such as food, sleep and hygiene.

Being afflicted by illness may make some persons think that it would be easier not to exist. They may perhaps also think about taking their own life. If you have suicidal thoughts, it is important to seek help so that you can feel better again. You can seek help here.

If you suspect that you have schizophrenia, you need to contact your own doctor. If your doctor finds that your symptoms may be signs of schizophrenia, he or she will refer you to a psychiatric examination.

If you have been referred for an examination for schizophrenia, you must:

• await a notice from one of our departments in your e-Boks or mailbox inviting you
• to participate in an initial consultation – preferably together with a relative – to clarify
  your situation.
• be prepared that you may have to go through several different examinations before it can be determined whether you have schizophrenia.

We always decide which examinations and consultations you may need based on a medical assessment. However, some things are part of a standard procedure.

You start with a consultation with a doctor, psychologist or nurse. Here you will be asked to describe your symptoms. If you have family or other relatives with you at the consultation, they can also help you tell about the symptoms.

You may need further examinations, as schizophrenia is a complicated diagnosis that differs greatly from person to person.

For a diagnosis of schizophrenia to be made, your symptoms must have been present for at least a month. The diagnosis is the psychiatrist’s working tool. It will be used to find the best treatment for precisely you. It is important to remember that you are not your diagnosis.
Your diagnosis is a snapshot of the symptoms that you have.

Before the diagnosis of schizophrenia can be made, it must be ruled out that there is a physical cause of your symptoms. This may, for example, be epilepsy.

If you have previously had cramps or serious head injuries, special attention will therefore be paid to whether it may be the cause of the symptoms. This can be ruled out through a number of examinations, including scans of your head.

There are various types of schizophrenia depending on which symptom is dominant:

• Paranoid schizophrenia, which especially involves persecutory delusions and also often hearing hallucinations
• Hebephrenic schizophrenia, where there is especially behavioural changes, with unpredictable mood swings, aimless and incongruous behaviour and/or incoherent speech.
• Catatonic schizophrenia, where movement disturbances are predominant.
• Undifferentiated (mixed) schizophrenia, where there are traits from one or more of the above types, but without these being sufficient to make one of these diagnoses.

Simple schizophrenia, where there are no psychotic symptoms, but a gradual decline in the ability to cope with the demands of society, accompanied by an impaired functional level.

The sooner you get treatment, the greater the chance that you will have a good course of treatment. The treatment is to contribute to ensuring that you have a course of milder, fewer and shorter episodes of illness and hospitalisations.

In the Central Denmark Region, schizophrenics are generally offered two years of intensive treatment.

The treatment is handled by a multidisciplinary team that uses a wide range of treatment forms. The treatment will be adapted to your needs. There will be focus on a number of areas, including that you:

• have a trusting relationship with a permanent therapist
• are offered medication for psychosis
• receive education in schizophrenia and in how to prevent recurrence
• get supportive consultations focusing on how you can master your difficulties
• receive support for a return to work/training/education/employment
• have the opportunity to involve your relatives as collaboration partners.

The treatment will always be based on your needs and how you can best be helped. We will also look at your overall situation. Because if the basic conditions are not in order (for example housing and finances), it can be almost impossible to focus on getting better.

The purpose of pharmacological treatment is to alleviate or eliminate your symptoms. This especially concerns the psychotic symptoms. The medication is also used to dampen anxiety, agitation and aggressions. Schizophrenia is treated with a type of medication called antipsychotics. There are different types of antipsychotics.

It varies from person to person which type of medication works best and also causes the fewest side effects. It may therefore be necessary to change medication to achieve the best effect and the fewest possible side effects.

Education about mental disorders is also called psychoeducation. Here, you and your relatives will receive education about schizophrenia.

Psychoeducation is often conducted in groups. Here, together with others suffering from the disorder, you will acquire knowledge about symptoms, causes, treatment, social services and early signs of a recurrence.

The psychoeducation is designed to increase your understanding of your own thoughts and actions and help create realistic expectations about your future.

Cognitive therapy is most often the basis for the psychological treatment of schizophrenia. In cognitive therapy, your therapist – together with you – focuses on examining and trying out alternative ways of thinking and acting in given situations. Here, you identify your problem areas – the thoughts and feelings associated with the problems – and you work to find new solution models and strategies.

The cognitive therapy includes the preparation of a crisis plan. It contains agreements on what you can do if you are feeling bad. You also work on how you can cope with signs of recurrence.

Finally, the treatment focuses on the extent to which past traumas influence your symptoms and behavioural patterns.

Social therapy may include the involvement of family, workplace, educational institution and municipal caseworkers. The municipal caseworkers decide what support options you may need. You may, for example, need help to cope with practical tasks at home, help to manage your finances or support to get out among other people.

Many people with schizophrenia also have substance abuse problems. The substance abuse most often consists of alcohol or hashish. But many schizophrenics also use other intoxicants such as amphetamines or cocaine.

Importance of intoxicants to the treatment

Intoxicants counter the effect of the medication used in the treatment of schizophrenia. Intoxicants also aggravate the psychosis, for example by increasing the effect of dopamine in the brain.  At the same time, intoxicants may be a way of forgetting your difficulties. For some, the substance abuse environment may be the only place in which they feel welcome, regardless of the problems they have.

If you have severe symptoms or your condition deteriorates periodically, you may be admitted to one of our wards until you feel better.

In Central Denmark Region, you may be admitted to these wards which treat schizophrenia:

• Aarhus (Skejby):
  • Ward 6 
  • Ward 7
  • Ward 8
  • Ward 10
• Herning (Gødstrup): Ward 2 
• Horsens:
  • Ward O1
  • Ward O2
• Randers: Ward A
• Viborg:
  • Ward P0
  • Ward P2

Compulsory admission

Most patients with schizophrenia voluntarily undergo a well-functioning course of treatment. If your condition deteriorates seriously, a compulsory admission may, however, become relevant.

Deterioration most often occurs because you stop taking the necessary medication or because of substance abuse that aggravates the psychosis.

• Your emotions become less strong

You have a hard time feeling your emotions or your emotions may seem less strong. You may also be in doubt about what you actually feel. And about your own identity in general (who am I?). You may seem less enthusiastic than usual, uninvolved or emotionally cold.

• Difficulty socialising

You may find it difficult to enter into relationships with others. You are in doubt about how to behave, and you tend to overanalyse everything. Many will begin to isolate themselves, as it requires a lot of resources for them to be with others.

• Jumbled thoughts

You may experience racing thoughts or a blank mind. Your concentration may be impaired, for example you may have difficulty finding the right words. Your way of thinking may
be different. You may begin to put words together in a new way that only makes sense
to yourself.

• Eccentric, quirky or outlandish behaviour or appearance.
• Strange ideas or magical thinking.
• Distrustful or paranoid ideas.
• Repetitive thoughts that may resemble compulsive thoughts, but where you do not resist them to the same extent. For example, these thoughts may have an aggressive content.
• Strong sensory experiences: for example you may experience that ordinary daylight suddenly blinds you or that sounds around you are amplified violently.

When you are attached to a clinic in the psychiatric services in Central Denmark Region, you get a regular contact with whom you have ongoing consultations. You agree with your contact how often these consultations will take place, based on your needs.

The consultations are based on cognitive therapy and will be of a supportive nature. They focus on the issues of importance to you right now. You and your contact will explore how you can handle these issues.

You and your relatives will be offered education about schizotypy – either in groups or as individual consultations.  Psychoeducation is an important part of your therapy. Here you can gain knowledge and understanding of your difficulties as well as guidance on how to master your symptoms.

Not everyone with schizotypy receives medication. A doctor will assess together with you whether you may benefit from medication.

There is a correlation between body and mind. For some, physiotherapy may therefore be part of the treatment.

Therapy in groups can be rewarding. Here you can meet other persons with schizotypy, and you can exchange experiences.

Social therapy may include the involvement of family, workplace, educational institution and municipal caseworkers. The municipal caseworkers decide what support options you may need. You may, for example, need help to cope with practical tasks at home, help to manage your finances or support to get out among other people.

It is important to prevent recurrence. This is especially important because we know that the more recurrences you have, the harder it is to recover. In many ways, prevention is about reducing stimuli and demands after a psychotic episode.

An important element in prevention of recurrence is the involvement of your family in your treatment. With knowledge about your disorder, your family can help ensure tranquillity and stability in your life.

Involving the rest of your network is also important, for example at your place of education or workplace.  What is demanded of you must be adapted so that the relevant considerations are taken.

• Seek out knowledge

It is important to learn how to tackle your symptoms. It is a good idea to accept offers of education about the disorder.

• Be aware of your early signs

The signs are personal. This means that all people have different early signs. Early signs of a new psychosis may be that you become more irritable, isolate yourself and sleep less before any deterioration. If you have schizotypy, a sign that your mental condition is getting worse may be that you are experiencing several micropsychoses or isolating yourself more than usual. If you have schizoaffective disorder, one sign could be experiencing major mood swings.

• Prepare a crisis plan

During the good periods, you can write down your early signs together with your therapist. You will then know when to seek medical advice or other help. It is also a good idea for you to agree, together with your closest relatives, who you should talk to if you become aware of signs. It is important in this connection that your relatives know the signals that indicate that you are at risk of having a recurrence.

• Prepare flashcards

Make a note of what benefits you when you are feeling bad. The cards may contain notes on what you need to do when you are in a difficult situation. The card may, for example, state: “When I am overwhelmed by voices, I should go for a walk or listen to music”. It is a good idea to have the cards on you at all times.

• Follow your pharmacological treatment

It is important that you comply with your pharmacological treatment for as long as your therapist recommends it. If you have any doubts or reservations about your medication, it is a good idea to talk to your therapist.

• Make sure to sleep well and eat a healthy diet

It is important that you have a stable daily rhythm with a good night’s sleep and that you remember your meals. Remember that small changes make a difference. This may, for example, be eating a little more low-fat food, drinking a little less cola and going for a daily walk.

• Exercise and do other activities that interest you

This could help alleviate negative thoughts and alleviate stress and discomfort.

• Avoid excessive quantities of alcohol

Alcohol consumption may prevent your treatment from being successful. High alcohol consumption may cause liver damage in the long term.

• Include breaks and rest in your everyday routine

It is a really good idea to organise your routine so that there is also room for breaks or for activities and other positive experiences that do not make great demands on you.

• Set goals that are realistic so that your experience is positive

Take one step at a time and practise lowering your expectations and not rushing thing. Pay attention to the small victories, for example that you have washed the dishes. Give yourself time – be patient even if it can be hard.

• Use mental training

You can set yourself mental tasks of a suitable degree of difficulty. If you cannot concentrate on reading a book, you might watch a movie or solve a Sudoku.

An important part of the treatment is to involve you as a relative so that you can provide support for the person who is ill. At the same time, it is important that you as a relative look after yourself, as being a relative of someone with schizophrenia, schizotypy or schizoaffective disorder may be stressful.  All sorts of feelings, such as anger, guilt, shame, fear and powerlessness, may come into play. As a relative, it is a good idea to participate in education about the disease (psychoeducation), where you can gain knowledge and understanding of the difficulties that may be associated with schizophrenia, schizotypy and schizoaffective disorder.

• Seek out knowledge. The more you know, the better you will be able to help in the right way.
• Participate in education or seminars for relatives. Here you can establish contact with other relatives of people with schizophrenia, schizotypy or schizoaffective disorder.
• Avoid over-involvement. It is important to respect each another as independent individuals and to avoid overstepping the other person’s boundaries.
• Accept that you do not always have the energy to provide the necessary help. We all have a limit for what we can cope with.
• Remember to look after yourself. Give yourself time and permission to find some places or activities where, as a relative, you can ‘recharge your batteries’.

Support the treatment

• Provide support for the treatment and the therapist. If there is anything you do not understand, ask. You may participate in one of the consultations with the therapist
  to hear what is being targeted.
• Pay attention to early signs of recurrence. If needed, make an agreement with your loved one that you may contact the therapist if there are signs of deterioration.
• Make room, let go and practise just being a relative and letting the professionals take care of the rest.

Be patient

• Focus on the areas where you can make a difference, and accept that you cannot solve every single problem. You cannot do everything! Help where you can. This may, for example, be with practical tasks. Accept that neither you nor others can do things to perfection.
• Solve the problems step by step and lower your expectations. Rome was not built in a day. Change takes time, and patience is important. Tiny steps in the right direction are better than trying to make major changes that end up failing.
• Provide support. You should try to avoid demanding too much. Express your own views and feelings instead of criticising. Remember also to praise and support your loved one in persisting with the treatment.

Be encouraging

• Remember: Schizophrenia, schizotypy and schizoaffective disorder are nobody’s fault! Self-reproach and recrimination will not change anything. Instead, look ahead.
• Hold on to hope. Help your loved one believe that he or she will get better.
• Avoid reproaches. No one grows by being blamed for what they are unable to cope with.
• Some people with schizophrenia have little or no awareness that they are ill. During such periods, it is important not to try to convince him or her of the opposite. You may instead simply support continued contact with the therapist.