BUDDY

One day I had to go out in the yard and sweep, and my mind was just wandering. I would sweep one spot for a long time, not conscious of what I was doing. It was like I couldn’t focus on the job. The pinnacle came a week before school started in my senior year. At my job they left me alone cooking hamburgers on the grill, and there was a rush. I was sweating scared because I didn’t know what I was doing. I told the supervisor I needed a break, that I had family problems, a lot of things on my mind. He told me to relax. He finally got somebody to help me out. A few days after that I quit.

There was one time I was managing the football team and I was in charge of keeping stats. I really felt out of place. Everything was surreal, in slow motion. It didn’t seem real. When the team scored I was quiet, and at halftime the math teacher came up to me. He was worried that I didn’t look too well. One of the guys on the team said, “What’s wrong with Buddy? He looks weird.” I was in denial.

These were the first episodes. I wasn’t going to school for a while. I stayed home for weeks and would not go out. My mother tried to get me help. Finally I had a bad panic attack. It felt like my skin was mushy, like I had extra fat, and my legs felt very heavy when I walked. So I was rushed to the ER. Then I went to a psychiatrist the hospital recommended. They said I had Attention Deficit Disorder. I was getting a lot of different diagnoses.

BEN: I was hospitalized when I was a junior in college. In my case it came on very sudden. It didn’t build up. It just happened. I remember my perception of situations, perception of just everything happening around me. At the time it seemed right to me, but to everyone else it seemed like I was acting in a bizarre way. At the time I thought there was nothing wrong with me, but with the other people.

It built up in a very short period of time and I got hospitalized. I remember every little thing I did that was bizarre. Mentally I could feel it too. My mind was not together. It was actually like muscles in my brain were having spasms. I could actually feel it in my brain. I cried at least ten times that night when I was admitted. I didn’t know what was happening. Every part of my brain wasn’t working. My judgment wasn’t working. What other people meant when they talked I would think meant something totally different. When my parents told me, “You are wrong, you are sick, you need to get help,” I didn’t believe that they were saying it because they wanted to help me.

I thought they were saying it because that whole night I was having this thought that some girl was in love with me. I thought she was in the house somewhere and I went all over the house looking for her. I thought my parents were hiding her. My mind just didn’t function like a normal person’s.

SCHIZOPHRENIA OR PSYCHOSIS?

It is important to be aware of the distinction between psychosis and schizophrenia. Psychosis is a general term used to describe psychotic symptoms. Schizophrenia is a kind of psychosis. Psychotic symptoms can include:

• confusion

• inability to think clearly

• difficulty putting thoughts together

• rapid thoughts that are hard to follow

• inability to pay attention or concentrate

• confused speech

• disorganized behavior

• hallucinations such as hearing voices, seeing visions, feeling like you are being touched, smelling foul odors—all in the absence of actual stimuli

• extreme fear caused by the strong belief that your life is in danger even though there is no reason for such a belief.

Several brain disorders can lead to psychotic symptoms, including lesions in the brain resulting from head traumas, strokes, tumors, infections, or the use of illegal drugs. If a serious depression goes untreated for a long time, psychotic symptoms may emerge. Elderly people with dementia may develop psychosis. People with bipolar disorder (also known as manic-depressive disorder) may become psychotic. These examples show that psychosis is not necessarily the same thing as schizophrenia.

ILAN: Nobody wanted to tell me what was wrong with me, but if I didn’t know what was wrong, if I didn’t know the diagnosis in layman’s terms, then I couldn’t help stop it, help fight it, help treat it in my daily life. I was asking all around and I was getting blown off: “What do you mean, schizophrenia?” “What do you mean, nervous breakdown?” “What do you mean, I’m psychotic?” Why can’t the doctors tell if you have manic depression rather than schizophrenia? Why was I thinking this way?

MAKING A DIAGNOSIS

Before doctors can arrive at a diagnosis of schizophrenia, they must make a thorough psychiatric evaluation. This includes a medical evaluation, a physical exam, a mental status exam, and appropriate tests. Some of the tests the doctors may recommend include the following:

• MRI (magnetic resonance imaging)—pictures of the brain made with special magnets to check for tumors or other structural brain changes

• CAT or CT scan (computed axial tomography)—pictures of the brain using special x-ray techniques to check for some unusual change such as a tumor

• EEG (electroencephalogram)—checking brain waves to check for seizures

• drug screening—testing the blood to make certain symptoms are not caused by a chemical substance

• blood tests—to be sure there is not an unusual viral, bacterial, or other illness that shows up in the blood that may be causing symptoms.

Also, a full history of the illness is taken that includes any changes in thinking, behavior, movement, mood, or sensory perceptions noticed by you or by family or friends.

Other diagnoses must be excluded. Remember, there are other psychotic disorders—bipolar disorder, major depression, substance abuse, and other medical illnesses—that share many of the same symptoms; these possibilities must be eliminated before doctors will diagnose schizophrenia or schizoaffective disorder.

To make a diagnosis of schizophrenia once other illnesses are ruled out, the doctor will be looking for psychotic symptoms and significant social or school/work problems. The doctor will also be checking how long the problem has been going on. For a diagnosis of schizophrenia there must be at least six months of some negative symptoms and/or positive symptoms. In addition, within those six months, there must be at least one month of positive symptoms or negative symptoms for most of a month (see chapter 4). This sounds complicated, and that is probably good because it means the doctor must consider your illness very carefully to make a diagnosis.

There are also special types of schizophrenia, which are called subclassifications.

TYPES OF SCHIZOPHRENIA

Subclassifications of Schizophrenia

paranoid type—frequent auditory hallucinations or one or more delusions

disorganized type—disorganized speech and behavior, and flat or inappropriate affect

catatonic type—extreme motor immobility; purposeless, excessive motor activity; inappropriate physical postures; and repeating words or behaviors

undifferentiated type—meets criteria for the general category of schizophrenia but does not fall into any of the other types

residual type—one or more episodes of schizophrenia have occurred in the past but the current illness is essentially negative symptoms and mild positive symptoms.

Schizophreniform Disorder

Schizophreniform disorder is an illness that meets all the diagnostic requirements for schizophrenia except for duration of the symptoms displayed. In other words, if there have been symptoms for more than one month but less than six months, then a schizophreniform disorder diagnosis is made. If symptoms last more than six months, then a diagnosis of schizophrenia is made.

Schizoaffective Disorder

Like other psychotic disorders, schizoaffective disorder can be a difficult diagnosis to determine. The person must meet all the criteria for schizophrenia and have significant mood symptoms. It must then be determined that the mood symptoms are not causing the psychotic symptoms. To do this the doctor takes a careful history to know whether there have been psychotic symptoms even when there have been no mood symptoms.

DOES HENRY HAVE SCHIZOAFFECTIVE DISORDER OR SCHIZOPHRENIA OR BIPOLAR DISORDER?

Henry thought the CIA was watching him and that someone had poisoned his food. Henry said his thoughts were going very fast and that he thought he had a special relationship with God. He was filled with energy and stayed up praying for two days. That is when his girlfriend brought him to the hospital. In the hospital all his tests came back negative. There were no drugs in his system and nothing was physically wrong with Henry.

When questioned, Henry and his girlfriend told the doctors he had been thinking people were watching him since last Christmas, nearly eight months earlier. He’d stopped going to work and was sleeping during the days instead of the nights until the past weekend. He said he was not really depressed but had been very frightened and anxious for the past few months. His girlfriend said he looked depressed because he would not leave the house. Then the past weekend he’d started to have manic symptoms (not needing sleep, high energy, racing thoughts, and grandiose thinking).

At this point the doctor had a very hard time deciding whether this was bipolar disorder or schizoaffective disorder, or possibly even major depression with psychotic symptoms. Over the next six months there were often times when Henry had manic symptoms: he thought God was talking especially to him and he had a lot of sexual energy. He was also very paranoid. Then there were three or four weeks when Henry had no manic symptoms or symptoms of depression but he was very paranoid. Now the diagnosis was much clearer. The doctor told Henry he had schizoaffective disorder.

The doctor made the diagnosis of schizoaffective disorder because there were periods when Henry had a mixture of psychotic and manic symptoms but he also experienced a period of over two weeks when he was not having any mood symptoms, only psychotic symptoms.

Schizophrenia Versus Mood Disorders

Bipolar disorder is often confused with schizophrenia or schizoaffective disorder, but it is not the same illness. It is a mood disorder characterized by manic, depressed, or mixed mood states. Symptoms of mania include elevated or irritable mood, grandiosity, decreased need for sleep, racing thoughts, distractibility, agitation, poor impulse control, and pressured speech. Depressive symptoms include sad mood, guilty feelings, poor appetite, and weight change. A mixed state has characteristics of both manic and depressed states at the same time.

The difference between bipolar disorder and schizoaffective disorder is that in bipolar disorder the mood is the main symptom. When the mood symptoms are gone the person returns to normal functioning. Similarly, in depression with psychotic symptoms, there are psychotic symptoms along with the depressed mood, and when the mood symptoms lift, the person returns to normal. In schizoaffective disorder, the mood symptoms may clear, but other symptoms continue.

Childhood-Onset Schizophrenia

Although most people who develop schizophrenia are in their late teens to mid-twenties, schizophrenia can begin at very young ages as well as much older ages. When we talk about childhood-onset schizophrenia we usually mean schizophrenia that starts before a child turns 13 years old. It is estimated that one child in 35,000 to 50,000 has schizophrenia, while the rate is one person in 100 for the general population. In other words, schizophrenia that begins before the teenage years is quite rare. Schizophrenia symptoms are the same in children as in adults, but childhood schizophrenia may be more difficult to diagnose and treat.

Children with schizophrenia often experience the same positive, negative, and cognitive symptoms discussed earlier in this chapter. They may hear voices, see things that are not there, feel things on their skin, or smell or taste strange things. They may feel confused, be frightened by delusions, lose their ability to attend to simple activities such as bathing and dressing, and have difficulties socializing with friends. As with other people struggling with schizophrenia, their hallucinations and delusions are based on their experiences of the world. This means that children will have psychotic experiences that are based on the television, movies, games, people, and places that they encounter. Cognitively, children with schizophrenia often have difficulty with memory and concentration required for learning. They may also have difficulties expressing thoughts and understanding what is said to them.

Although the symptoms of schizophrenia are very much the same as for all other people with schizophrenia, it is important to recognize that the symptoms are happening to children whose bodies are growing and changing every minute. Children’s brains mature in complex ways that allow them to take on new social, educational, and emotional challenges. They make new friends, learn new skills, and begin to learn about who they are in relation to the world. Schizophrenia disrupts this process so that is very difficult to mature socially, emotionally, and behaviorally.

Children with schizophrenia may also have additional psychological problems. In the same way as older people, they may also have other disorders such as obsessive compulsive disorder, anxiety disorders, and mood disorders. Some children with schizophrenia also have pervasive developmental disorder (PDD). Children are said to have PDD when they have delays that show up early in development, usually by age three or four. They may have difficulties relating to friends, communicating, or imagination. They may do things like flap their hands, say things over and over, or get stuck doing something over and over. Some children with PDD also experience hallucinations now and again, making it very difficult to tell whether a child’s symptoms are due to PDD or schizophrenia. Since both PDD and schizophrenia may lead to delays in development and psychosis, the diagnosis of schizophrenia may be added if a child has psychotic symptoms that continue over many months, occur in all areas of life (school, friends, and home), and affect functioning so that the child is unable to do the usual things expected for a person his or her age.

As with adults and teenagers, it often takes time to tell exactly what is going on when children are having problems with thinking, feeling, and behavior.

Additional information regarding diagnosing schizophrenia:

NIMH:

http://www.nimh.nih.gov/health/publications/schizophrenia/index.shtml.

You can also order a copy of the publication (English or Spanish).

NAMI: www.nami.org. Follow the link to “schizophrenia.”

Diagnostic and Statistical Manual of Mental Disorders: DSM-IV (American Psychiatric Association, 2000).