Schizophrenia is a complex brain disorder that affects how a person thinks, feels, and behaves, leading to a distorted perception of reality, often characterized by hallucinations (seeing/hearing things that aren’t there) and delusions (false beliefs), disorganized thinking, altered emotional expression, lack of motivation, impaired executive function, problems with social interactions and other cognitive functions. There are two major categories of Schizophrenia – those that respond positively to antipsychotic medication (implying that Dopamine Receptor 2 [D2] is key), and those that don’t (implying that it isn’t D2). Some people are misdiagnosed with Schizophrenia simply because the diagnostician didn’t understand the person, or mistook an aspect of the above description as sufficient to apply the Schizophrenia label to them. Hearing Voices (or some other sensory perception difference) does not automatically mean you have Schizophrenia.

Understanding Schizophrenia

Being diagnosed with schizophrenia requires a medical doctor (GP) or psychiatrist. Most commonly they diagnosis based on the guidelines of the USA’s DSM. The ICD should be applied in Australia, however most diagnosticians are trained on the DSM and just translate the diagnosis to the ICD code in public systems.

Much like Autism, Schizophrenia is frequently referred to with Spectrum added after it. That is, Schizophrenia Spectrum Disorder, mostly due to the DSM combining the various versions of Schizophrenia under a single diagnostic criteria, and with the USA being very strong in defining the English language, it has been adopted on may web forums. A common variant of Schizophrenia Spectrum is Schizospec.

Diagnostic Criteria (DC)

Diagnostic Criteria is the system that a diagnostitian, such as a GP or Psychiatrist, use to differentiate between someone who does and does not have the condition. DC is not suppoed to be used to treat or actually understand the condition, just to tell if this disorder is correct for this person or not. Unfortunately, many people mistake the telling points for diagnosis with guidelines to understand the condition or treat the condition.

DSM 5 TR DC

The DSM is the USA Diagnostic and Statistical Manual of Mental Disorders, which many other countries also use. This is the latest version (at time of writing), Version 5 Text Revision (5 TR). Most of the online community use the DSM as the reference discussion point rather than the ICD, even if in some cases the ICD is better and less USA centric.

Discussion on the DSM Diagnostic Criteria

Overall Opinion of DSM DC

The DSM 5 TR diagnostic criteria do an adequate job of trying to describe what you are likely to see when you come across someone who is schizophrenic. Unfortunately, it fails to truly describe what it is like to meet someone with this condition. There is a look & feel that is very hard to adequately describe in a system like the DSM’s Diagnostic Criteria. This look & feel is about how a person processes information and their surroundings at a deeper level (the thought disorder side of things hinted at by “delusions”) and a look around how the eyes and facial expressions work. When you know what to look for in this look & feel, it is unmistakable that the person you are interacting with has schizophrenia, or that the person so described as being schizophrenic due to meeting the criteria is in fact not schizophrenic. I have had quite a few clients that were diagnosed with schizophrenia but weren’t. On average, they were Autistic people with rotten situations and or Voice Hearing.

Hearing Voices is not schizophrenia. In my opinion, the DSM 5 TR does not make that clear enough. I note in my analysis above in Part F: Autism and Communication Disorder consideration that delusions and hallucinations are not enough to define an Autistic person as having schizophrenia. An Autistic Voice Hearer will likely get the diagnosis of Schizophrenia because the uneducated diagnostician mistakes the Autism mode of thinking for the Schizophrenia mode of thinking (dellucions, disordered thinking – because they didn’t follow how the Autistic person thinks) and the Autistic facial affect for Schizophrenia facial affect, and on assuming that the patient is schizophrenic, did not check the circumstances to see if it is true. I have debunked a few Schizophrenia diagnoses upon recognising that the person was Autistic ADHD and that no one checked if the so called “hallucinations” (eg distress when hearing people argue behind a wall) were not in fact actual people arguing behind the wall leading to the empathic AuDHD being distressed.

When I was working in a Psych Ward, I was taught the basic division of symptoms / traits as positive, negative and sideways. Positive is when you have an experience that most others don’t, for example hearing voices or paranoia. Negative is when you are missing a trait that most others do, such as anhedonia (the absence of joy). Sideways is more about psychosis, the delusional thinking or disconnected thinking, or put another way, the wonky reasoning someone uses to explain things very strangely compared to the consensus typical explanations. I would add in hyper – hyper is a typical (common) trait, but much stronger, such as sensory hypersensitivity (versus the typical sensory experience). I found this quite a useful tool to understand what the diagnosed person experiences as different to typical, and to try to see if there is an example of each direction (positive, negative and sideways – hyper is more useful for assessing Autism). While this conception may have fallen out of use these days, I think it is still helpful.

ICD 11

The ICD is the International Classification of Diseases published by the World Health Organisation under the United Nations. It strives to be culture independent and inclusive rather than inclusive, which the DSM often does not do as well. Below is taken from the latest version (at time of writing) Version 11. The ICD is quite different to how it manages the diagnosis of Schizophrenia from DSM. ICD has a primary version of Schizohprenia, a more classic interpretation for F20, and then the subtypes of Schizophrenia are listed via different decimals, .0 to .9. For example, if you fit the criteria for Paranoid Schizophrenia, you would only use code F20.0 Paranoid Schizophrenia. If no subtype is apparent, you would use F20.3 Undifferentiated Schizophrenia.

Discussion on the ICD Diagnostic Criteria

Unlike DSM, ICD separates out 10 different subtypes beyond the main diagnosis for schizophrenia. DSM removed the subtypes. The subtypes seem mostly useless and stigmatising. While it may be useful to know that this person is often experiencing paranoia, does this person really warrant an entire different label and F code?

ICD does not actually infrom you about what needs to be present for the person to be diagnosed with schizophrenia – do you need each of the descriptions to represented, just 1 or a specific number in between? This can lead to under or over diagnosis and general confusion.

ICD lists other names for specific F codes. For example, F20.0 Paranoid schizophrenia may also be known as Paraphrenic Schizophrenia. It doesn’t make it clear that this is what it means – I have added “Also known as” and a green bar to help guide understanding.

ICD lists exlusion diagnoses. That is, F20.0 Paranoid Schizophrenia cannot also be listed with F22.8 Involutional Paranoid State via the section prefix Excl.:, which in my opinion was not clear. This helps the diagnosis to not double dip on symptoms and hopefully the person is given the best fit diagnosis.

ICD also includes F.21 Schizotypal disorder, F22.X Persistent delusional disorders, F23.X Acute and Transient Psychotic Disorders, F24 Induced Delusional Disorder, F25.X Schizoaffective Disorders, F28 Other Nonorganic Psychotic Disorders and F29 Unspecified Nonorganic Psychosis in the Schizophrenia Block of disorders as they are seen to relate to people likely to be diagnosed with Schizophrenia, but are not technically Schizophrenia. I have not included those in the above. If you wish to read the details of these, follow the link for the Source.

Overall Opinion of ICD DC

ICD Diagnostic Criteria is not very helpful in determining if a person fits the criteria or not. While it describes what you would expect to see, it doesn’t help you figure out if the person meets enough of the description that you would give them this diagnosis or not.

The subtypes may be useful in some instances, however generally they are not and it may be that the person who presents as one of these, for example Catatonic Schizophrenia may not be Schizophrenia at all. According to the description, when the person isn’t mindlessly complying with instructions or unable to act, their behaviour seems weird. If we only looked at their seemingly conscious behaviour as described, would we diagnose them with Schizophrenia – that is in the absence of the catatonia states, the description doesn’t resemble schizophrenia, so why is it here?

Overall, this diagnostic system seems awful and confusing.

Treatment

Antipsychotic Medication

Antipsychotic Medication has a positive effect on around half of the people diagnosed with Schizophrenia and has no major benefit for the other half. For the half that don’t experience benefits from the medication, some of the support networks benefit from the sedating aspects of the Antipsychotic medication. Medication compliance is often poor.

Antipsychotic medication blocks Dopamine Receptors, which decreases these misfirings and allows the person’s brain to compensate adequately in real time so that their Schizophrenic symptoms appear to be reduced or in remission. There are a few generations of Antipsychotic medications. The original Antipsychotic medication, referred to as just “Antipsychotic medication” or “typical Antipsychotic medications” blocks all 5 of the Dopamine Receptors. The group called Atypical Antipsychotic is the latest medications that target some of the 5 Dopamine Receptors, allowing the remainder to work mostly as normal, or only partially reduced instead of disconnected. An Antipsychotic works by filling a Dopamine receptor without triggering it, blockading Dopamine from being able to lodge and trigger – effectively disconnecting that circuit. All medications that are called Antipsychotic need to blockade the Type 2 Dopamine Receptor (D2).

Around half of people diagnosed with Schizophrenia are sensitive to having excess Dopamine, or just have overactive Dopamine receptors (that is, you might have the normal amount of Dopamine, but your synapse over reacts to it, so similar in effect to having too much). The Dopamine over triggers certain Dopamine receptors which triggers other neural network pathways that interfere with reality checking, which often also leads to an increase in creativity. This results in psychosis, where the psychotic person can’t confidently tell what is real and what is false – aka Delusions and Hallucinations. In attempting to make the world make sense, the Schizophrenic person will often create connections that other people don’t, which looks like disordered thinking, delusions and disorganised speech – three of the symptoms of Part A of the DSM diagnostic criteria. Difficulty with Dopamine supply to the Dopamine receptors and commonly oversupply of Noradrenaline (which is converted from Dopamine – see the Dopaminergic System for an explanation) will often lead to poor impulse control, difficulty in focusing & concentration, mood dysregulation and generally executive dysfunction – aka Grossly disorganised and or derailment of conversation.

There is some fascinating research that shows that a commonality in some forms of psychosis, where the D2 receptor triggers a pathway to the Serotonin 5-HT2A receptor via a glial cell. Blocking only the D2 receptor and blocking only the 5-HT2A receptor doesn’t seem to strongly affect psychosis, so currently the hypothesis is the intermediary glial cell may be the core part of the disorder. We don’t have a medication yet that disables that glial cell. More research is needed.

Due to the Dopamine blockade caused by Antipsychotic medication, the speed of thinking decreases and many Schizophrenic people complain of brain fog – the struggle to think coherently and on command. This often leads to many Schizophrenic people smoking cigarettes and consuming copious quantities of caffeine to offset this aspect of the medication [Source 1, Source 2, Source 3]. Even beyond the Dopamine blockade, many antipsychotic medications act as sedatives, decreasing emotional response and reducing exacerbated behaviours – which often isn’t useful for the diagnosed person, but might be helpful to the support network.

Psychiatrists tend to reach for antipsychotic medications first, second and third and are often reluctant to admit when their patient is in the 50% where the medication isn’t helpful to them. This plus the side effects of antipsychotics are the main factors in poor medication compliance – people would rather struggle with their symptoms than deal with the medication.

There is one other major reason why medication compliance can be poor – a lack of insight. Many times have I come across people who do well on the medication, but don’t recognise that the medication is why they are doing well. To them, since they are well, they don’t need medication, so they stop. It doesn’t take long for them to stop doing well, but since they can’t connect the absence of medication to them doing poorly, they don’t start the medication again and so they do worse. Once they are back in psych ward, they start to do better again, since they are now required to take medication. This insight medication problem is the most prevalent in Schizophrenia, but is not exclusive to Schizophrenia.

Other Medications of Note

As noted above, around half of the people diagnosed with Schizophrenia do not find their symptoms managed by antipsychotics. That is, the symptoms that resulted in a schizophrenia diagnosis are not reduced or eased. Often these medications are prescribed anyway for their sedating qualities, helping the person be more easily managed by others.

Beyond this, official medication for the specific symptoms of Schizophrenia don’t exist. Even so, there are some other options that can work for some people when either taken off label, or to treat specific symptoms you have as part of your condition rather than “Schizophrenia”.

Some Schizophrenia symptoms can be due to excess Noradrenaline in the midbrain, often managed well with Noradrenaline reducing or moderating medications such as Clonidine, Propranolol or other Beta Blockers. The Noradrenaline surge may be due to a secondary action to do with sex hormones, specifically Oestradiol, so it is essential to check thyroid function, LDL cholesterol and Oestradiol. If you have a uterus and active ovaries, it is important to test both the peak and trough levels of Oestradiol. Oestradiol is a factor in people without these organs too, but often without peaks and troughs.

While SSRI (standard antidepressants) can help with some of the symptoms of Schizophrenia, these medications are insufficient on their own to make a significant effect. SNRI, such as Desvenlafaxine or Venlafaxine, can sometimes help more than SSRI, if the person has low neuronal Noradrenaline rather than high levels.

ADHD is rare amongst true Schizophrenia. ADHDers literally struggle to get enough Dopamine to their synapse receptors, while Schizophrenia has too much. It is possible for someone to have a nasty combination deal, where the Goldilocks Zone of the right amount of Dopamine is fragile, easily too low creating brain fog and mood dysregulation, easy to be too high creating Schizophrenia symptoms. Modafinil can sometimes be effective in these cases, helping to buffer the Dopamine so it doesn’t get too low, but also moderating it so it doesn’t get too high. Modafinil causes minimal euphoria compared to other Dopamine based stimulants.

One of my clients gained significant cognitive function and impulse control with a combination of birth control hormones (mixed pill, skip the placebo pills), Desvenlafaxine and Modafinil. I recommended these medications to stabilise Oestradiol, boost baseline Noradrenaline, boost baseline Serotonin and moderate Dopamine from being either too high or too low. This same client did need to use the occasional Clozapine (Antipsychotic) PRN (Pro Re Nata aka as needed) when their natural hormonal cycle exceeded the regulation from their hormone pills. This combination was effective for this client, and is not likely to suit most people diagnosed with Schizophrenia – the point is that sometimes when regular or atypical antipsychotic medications are ineffective, it is useful to consider other medications to target different neurotransmitters and body functions that may explain the persons symptoms – that is, seeing beyond the label.

Talking Therapy

Treating Schizophrenia through talking therapy is hard.

We are going to address this in three layers.

• Therapist attitude
• Cognitively impaired
• Cognitively intact

Therapist Attitude

At its core, people experiencing Schizophrenia are going to have a different way of seeing the world. It is important to try to work within their paradigm of the world without reinforcing harmful ideas, but also not having to correct all of their misconceptions. Try to think of it more as a person from a very different culture. How would you explain to someone from a different culture a guideline or rule for this culture that makes sense to them from their perspective? When you can do this, it often helps them understand what change they need to make far better than trying to enculture them to how you see the world first, then push them to change.

This is hard to do. It is very tempting to try to correct or challenge everything.

Often people will jump around many topics and not spend enough time on any one topic to do any examination or challenge an idea. Initially, let them jump around so that you can get some idea of what their paradigm is. Use some questions about how, what and why to slow them down a bit so that you can get an idea of how things connect for them. All humans have a sense of how the world works built on what we perceive and remember. We will often change what we remember to fit in better with our ideology or paradigm, which can mean faulty memories. As most people with Schizophrenia have distorted perceptions (delusions / hallucinations) the paradigm to explain the world is going to be quite different to what you are used to – so it is important to glean enough of what is going on to work within their framework of the world.

Once you have an understanding, it is time to start challenging a few things that are not helping them, ideally from within their paradigm and sometimes with external facts.