The following by Merrell Dow explains the various symptoms someone with schizophrenia may have & how best to respond.

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Schizophrenia is a (biological) disease (of the brain) that ebbs & flows. Acute periods are called "relapses" when patients experience sensations that are an addition to their usual repertoire of feelings. Because they are additions, they are referred to as "positive symptoms" but they are far from positive in the sense of being wanted. They are the hallucinations, delusions & thought confusions which return periodically, triggered, probably, by a variety of stresses. They respond, in general, to decreased stimuli, calm interactions, & antipsychotic medicine.

Interspersed between the acute periods are various stages of convalescence during which patients frequently experience "negative symptoms". These are subtractions from the normal repertoire of feelings such as loss of interest, loss of energy, loss of warmth, loss of humor. In general, these do not respond to medical interventions but require more difficult psychological assistance. (Note: Since this note was written, clozapine, resperidone and other drugs have been introduced which can help with negative symptoms.)

Hallucinations

Hallucinations are false perceptions, inaccuracies that affect our senses & cause us to hear, see, taste, touch or smell what others do not. In the acute phases of schizophrenia, patients are likely to insist they are hearing voices that no one else can hear. Sometimes they hear noises, clicks or non-word sounds. On occasion they are disturbed by seeing, smelling or feeling things that others do not.

Descriptions of these perceptions differ. Sometimes they are experienced as very forceful & apparently important thoughts. Frequently they seem to come from outside the self & are heard as conversations between other people, or commands, or compliments (or insults) addressed to the person. Sometimes the voices are reassuring, at other times menacing. Often the remarks heard are not addressed to the person but seem to be concerned with them in an unclear (but perhaps derogatory) way. Individuals who experience this describe it "like a tape playing in my head". The experience is so real that many schizophrenics are convinced someone has implanted a broadcasting device in their bodies. Or they come to believe in a supernatural explanation for the strange sensation. It is so real to the person that it cannot be dismissed as imagination. During periods of convalescence, patients are in control of their "voices"; they can often summon & dismiss them at will. Or they may learn to ignore them, or treat them as benign accompaniments of everyday living. But during acute periods, the hallucinations, usually the same ones over & over, take control & the patient feels victimized, powerless, at the mercy of a "foreign presence".

Patients themselves, & those close to them, must recognize hallucinations as symptoms of illness. Discussions about their objective truth or plausibility are not valuable. The experience is true & very vivid & has to be accepted as such. Attempts to "set the person straight" result in resistance, tension, & bad feelings. It is, however, helpful to clarify that others do not hear, see, smell, or feel what the patient is experiencing. This helps to identify it as a special experience of the patient whether he can or can not accept it as a symptom of the illness. At least everyone can agree that something is happening.

Hallucinations respond to a lessening of stress & an increase of antipsychotic medication. Keeping busy is important as it provides helpful distraction. Competing stimuli can sometimes "drown out" the voices. Encourage the patient to discuss when the hallucinations occur & what they say with his therapist. This can clarify the nature of the stress that tends to bring them on. Another useful strategy is to point out to the patient that he has some control over the hallucinations. Often, unconsciously, the patient has developed the habit of of listening for his voices, as if he were a passive recipient. Directing his mind to other interests, & helping him recognize he need not wait for incoming voices, can be surprisingly effective. These are techniques that the patient develops for himself over time & that require a fair amount of trial & error. Encouragement to persevere, not to give up, to discuss things with the therapist & reassurance that the family & close friends understand, are important. Constant talking about hallucinations can be exasperating but it is understandable that the patient is preoccupied with such extraordinary events. Chronic hallucinations must be accepted as part of everyday life & are not usually sufficient reason to excuse participation in activities or household chores.

Delusions

Delusions are false beliefs or misinterpretations of events & their significance. For instance, a person may get accidentally bumped in the subway & may conclude that this is a Government plot to harass him. He may be awakened by noise from his neighbors apartment & may decide this is a deliberate attempt to interrupt his sleep. Everyone tends to personalize & misinterpret events, especially during times of stress or fatigue. What is characteristic of the schizophrenic however, especially during an acute period, is that the conviction is fixed & alternate explanations for the events experienced are not even considered. Usually attempts at reasoning or discussion about possible other meanings of the bumping or the noise in the night can only lead to the further conviction that the reasoner must be in on the plot, too. Arguing with a delusion only leads to further mistrust or anger. The beliefs are tenaciously held, against all reason, & they are characteristically not shared beliefs. They are held only by the person himself & by no one else.

Families & friends must first realize that delusions are a result of illness & not stubbornness or stupidity. Although fixed delusions can be irritating, emotional reactions should be avoided, as should taunts or threats. There is almost always something about the delusional belief that can be empathized with. For instance: "Getting bumped in subways is very annoying. It must make you feel as if no on cares, no one pays attention, that you're not important enough to get an apology or an 'excuse me'." (Presumably the belief that one is at the center of a government plot must derive, at least in part, from the fear that one is really very unimportant or worthless.) Or: "Getting awakened at night is terrible. It's so hard to get back to sleep later. It saps you of all your strength. If you feel your neighbor is not your friend, it is important to be strong & healthy." (This kind of reasoning may persuade a person to seek medical attention &/or an increase in his medicine in order to be strong & fend off annoyances by others. It works better than saying, "You're deluded, you had better see the psychiatrist."

Another approach is to help cut down the stimuli that lead to delusion formation. If crowded subways bring on experiences that lead to persecutory ideas, avoid them. An emergence of delusional ideas, whether persecutory or grandiose (thinking one is special) usually means there is too much activity or emotion, perhaps too many people around. Example: "I think I am Jesus." Unhelpful response: "That's totally irrational. You're crazy." Helpful Response: "I guess you feel really special & different today. Maybe it's all the excitement around here. Let's try a very low key routine for the next few days." When well on medication, if the person persists in talking about left over delusions, a helpful response would be, "That's how you see things. I have explained that I don't agree--we will have to agree to disagree." (This acknowledges his view yet stops pointless discussion.)

Talking Nonsense

This generally occurs when a person is in the active phase of his illness. It can re-emerge sometimes when medications are too low or stress is too high. What the patient says becomes incomprehensible to those around him either because sentences are unconnected to each other, or else because there seems to be no point to the stories told, or else because topics seem to switch with great frequency. Words may take on special meanings in schizophrenia either because they trigger private associations or because attention is paid to individual sounds rather than hole words. For instance "psychiatry" may sound like "sigh Kaya tree" & the topic may switch suddenly from a discussion of psychiatry to a discussion about mystical trees. Certain words may be avoided because they sound harsh or evil. Sometimes intonations are changed for similar reasons. Sometimes language is used as an incantation to ward off threats. Difficulty making sense to others is a symptom of the acute phase of the illness. It is almost impossible to communicate with patients when they are in this phase & it is very frustrating to family.

Try to communicate non-verbally. Sometimes communication through writing works, as thoughts tend to be more organized in writing. Do not force yourself to listen & understand; it will usually lead to headache & irritation. When talking to others, however, do not speak as if the patient were absent. Do not tease or mimic him. Most people use one side of their brain for language & the other side for art or music or movement. If the language side is disturbed, it might be a good idea to concentrate on the other side & encourage patients to draw, sing, or play an instrument, to exercise or dance. These are other ways of communicating which might prove to be effective.

Like other positive symptoms, thought disturbances respond to a reduction of stress & an increase in antipsychotic medication. Preoccupations These are fixed ideas, not necessarily false (like delusions) but overvalued. They take on extraordinary importance & take up an inordinate amount of thought time. One idea often returns & returns. Frequently it is a worry about doing the right thing or doing it well or in time. Characteristically, the worry grows & becomes unrealistic. A common sequence of events is for the worry to take up so much of a person's time that the "right thing" does not get done & its not being done is then attributed to the bad motives of others. Or it may be rationalized as God's wish. OR, frequently, the person may decide he's physically unable to carry out the task.

Example of unrealistic explanation: "I can't get up because I'm paralyzed." "I'm supposed to stay in bed today because it's the Lord's day." "If I get up, I'll get hurt." These kinds of explanations sound odd to others but to the schizophrenic they seem warranted. They do not understand why others see them merely as "excuses". To them they explain the facts better than any other explanation. Sometimes these preoccupations have a mystifying character to them. They seem to require puzzling over & decoding.

The schizophrenic spends much time in this kind of puzzling activity & that is why he thinks he has solved mysteries that others haven't, since they spent no time at it. When lost in thought, schizophrenics do not want to be distracted. They feel they have important work to do to try & come to the bottom of the puzzle & they do not appreciate offers of conversation or shared activities at those times. Preoccupations are usually seen in the active phase of the illness but may continue into the convalescent stage. They may take the form of daydreaming.

They must not be allowed to control the life of the patient or the life of those around him. Distraction is helpful as is a structure or daily routine that does not permit too much time for sitting & thinking. The necessities of life: sleep, good food, exercise, fresh air, cleanliness, health & social interactions must be maintained. Preoccupations must not be allowed to interfere. Increased meds may be required.

Violent or Aggressive Behavior.

This is not really a symptom of schizophrenia but when it does occur, it tends to occur in conjunction with hallucinations, delusions, preoccupations & jumbled thoughts. It, too, is triggered by stress & abates when antipsychotic medication is taken in appropriate amounts. Violent behavior is much more frequent in mental disorders that have nothing in common with schizophrenia. It is described here mainly because patients & families are so frightened of it & it leads to so much dread & worry. It is most common in young men. It can be precipitated by psychological or chemical stimulants.

Violence against others is often a result of misinterpretation of their intent & a resultant feeling of being cornered. A person in the acute stage of schizophrenia may exaggerate other's irritation & misread it as fury. He may see ridicule in what is meant as jest. He senses himself in danger when he is not & may strike out under those circumstances. Violence against the self is more common & is discussed under depression. In an attempt to prevent violence, try to avoid blame, ridicule, confrontation, teasing, or insult.

Allow your schizophrenic relative privacy & psychological distance. Should violence erupt, however, do not allow yourself to be intimidated by it. Take whatever measures are necessary for the safety of everyone concerned. This may require firmness or help from friends & neighbors. It may require summoning the police. Let the patient's therapist know if violence erupts at home. Ask the therapist for pointers on how to help the patient develop self-control. In addition, always maintain an up-to-date list of helpful community resources

(See "Important Phone Numbers" and "Preparing for an Emergency" enc. Ask for "Directory of Mental Health Services" for your borough from the AMI/FAMI office-ed) You may find through experience that the patient responds best to certain friends when he is frightened, distressed & potentially violent. Call upon these friends in times of crisis. The best way to prevent dangerous moments is to anticipate them & be prepared with an effective plan of action, should they occur.

Although violence is not common is schizophrenia, it may become a pattern with some schizophrenics. If so, discuss appropriate living arrangements & appropriate anticipatory & preventive measures with the therapist. Restlessness Restlessness, anxiety, tension & agitation are words describing similar states. None of these are positive symptoms of schizophrenia but, like aggressive behavior, they tend to occur in conjunction with the positive symptoms. They may result from fear & apprehension, as a response to the frightening aspects of hallucinations & delusions. If this is so, they require quiet, calm reassurance. Patients who are so anxious about what is happening to them need to have someone near to provide explanation & stability. The reduction of stress & the introduction of medicines will reduce anxiety as well.

Restlessness that begins after the patient is started on medication may be a secondary effect of the drugs. This kind of restlessness usually appears as a shaking of the legs & a need to pace the floor. Patients may be seen to move from one foot to the other or, when sitting, shake their legs up & down on the ball of the foot. At the dinner table, this constant motion may cause the whole table to shake.

Another commonly observed movement is tremor. This is a rhythmic contraction of muscles, usually seen in the extremities. The tremor is usually not particularly bothersome to the patient unless he plays the piano or uses the typewriter. The restlessness, however, is very uncomfortable. The patient has some control over it, can stop it for a few moments at a time but it comes back the instant he lets his attention waiver. It can be quite agonizing for some patients & needs to be reported to the doctor who can change the dose of antipsychotic drugs or add side-effect medicine which will make this restlessness disappear. The same procedures will reduce the tremor that is secondary to the medicine.

After many years of antipsychotic drug use, some patients develop other kinds of movement disorders, usually jerky movements around the mouth & extremities. These are not usually uncomfortable but can be unsightly. The prescribing doctor must be made aware of them & will adjust the dose of the drugs accordingly. These movements are more difficult to control. They may, in fact, become worse for a time after the drug dose is lowered. In most cases the movements gradually wane if the drugs can be discontinued for a prolonged period but that is sometimes risky because the patient may become acutely ill again.

Restlessness & tension, whether psychological or secondary to drugs, is made worse by stimulants (coffee, tea, cola drinks, chocolate, cold tablets). Sedative medication helps but should only be used with the advice of the prescribing doctor. Understanding helps. Do not criticize the patient for pacing. Instead, try accompanying him for a walk, encourage exercise, jogging & bicycle riding. If the pacing becomes unbearable in the house, suggest other areas, outside the home, where the patient might walk about without disturbing others.