It is extremely upsetting when, after a period of disturbed or difficult behaviour, a relative or friend is diagnosed as having schizophrenia. Because of the many misconceptions based on ignorance about this illness, it is natural that everyone concerned is apprehensive about what will happen, particularly as it often begins in young people with their future before them.

There are several important facts to bear in mind at this time. Firstly, schizophrenia is an illness which, although disruptive, can be treated and most sufferers respond to medication and can return to a normal or near-normal life. About a quarter of those treated recover within weeks or months and the illness never returns. About half recover but have further bouts of illness. Sadly, the remainder do not respond well to treatment and may remain ill for a long time.

Second, schizophrenia is not physically disabling like some illnesses that attack young people such as multiple sclerosis or rheumatoid arthritis. Nor is it, in itself, life-threatening, although one in seven sufferers commits suicide.

Today, there are organisations like SANE, National Schizophrenia Fellowship and MIND which exist to help individuals and their families. However, since schizophrenia can last a long time, those involved should learn as much as they can about it.

UNDERSTANDING THE ILLNESS
Schizophrenia is the most common serious mental illness. It affects one person in a hundred at some time in their life. It can start at any age but most commonly begins in the late teens or early 20s. More or less equal numbers of young men and women become ill, but women are usually 4 or 5 years older than men when it starts. A quarter of a million people in Britain have schizophrenia today, although many of these have the illness under control. Schizophrenia has been described in all cultures and its incidence (about 1 in 100) is much the same in every country.

Many illnesses affect the way we think and experience things. Influenza and other illnesses involving very high fevers may cause delirium defined as "a disordered state of mind with incoherent speech, hallucinations and frenzied excitement". But nobody would describe these fevers as mental illnesses. Such physical illnesses also have physical symptoms and can often be diagnosed from abnormal functioning of some part of the body as measured in laboratory tests. Mental or psychiatric illnesses do not have specific physical symptoms which can (as yet) be measured in the laboratory and the abnormal state of mind and bizarre behaviour which are often the main symptoms are usually prolonged, although they may appear or disappear of their own accord. This makes it difficult for the doctor who can only judge what illness his patients are suffering from by the unusual experiences and behaviour they describe.

SCHIZOPHRENIA IN RELATION TO OTHER MENTAL ILLNESSES
Schizophrenia is one of the most severe of the common mental illnesses. It is one of the psychotic disorders with symptoms such as hallucinations, delusions and thought disorder that show the person has lost touch with reality. Psychoses are of two types: organic and functional. Organic psychoses are due to recognisable medical illness like the delirium that may accompany a fever or the senile dementia that is a feature of Alzheimer's Disease. Functional psychosis such as schizophrenia is not attributable to a known condition or illness.

SYMPTOMS OF SCHIZOPHRENIA
Schizophrenia has many different symptoms which has led some people to suggest that it may be a whole family of illnesses. Symptoms fall into two groups. The first are called positive or florid symptoms some of which are listed in Table 2. One of the most common florid symptoms is hearing voices which may demand that you take certain actions. Sometimes you can be seen arguing fiercely with your voices in the street, often frightening people who do not understand what is happening. Sometimes a young person sits with a record player blasting into his ears in an attempt to drown the demands of his voices. The symptoms may often include unusual experiences or beliefs which affect behaviour. For example, you may feel the whole world is against you, even members of your own family including those who are doing their best to help. Modern medicines will usually control positive symptoms, however alarming they may appear.

The second group of symptoms are called negative. They come on much more slowly and don't respond to treatment so well. Someone with these symptoms will withdraw, give up his friends, be unable to communicate effectively with others, isolate himself for instance by rarely leaving his room. Table 3 gives the most common negative symptoms of schizophrenia.

Negative symptoms cause a lot of distress both for those who are ill, who struggle unsuccessfully to communicate, and for their families, who feel unwanted and unloved. It is hard for them to understand what has happened and why their child has become unable to hold down a job or look after a home. These symptoms irritate and distress families more than positive ones which, because they. are 'nonsensical', are more acceptable. Relatives often blame negative symptoms on laziness and lack of effort instead of recognising that they are due to an illness.

DIAGNOSIS
Because there are no physical symptoms of schizophrenia which can be measured for example by blood tests, the psychiatrist has to rely for his diagnosis on your behaviour and the symptoms you describe. Diagnosis is difficult because the course of the illness is lengthy and some of the classic indications of schizophrenia may be delayed in appearing or may appear so slowly that only a family member would notice the change. The psychiatrist faced with making a diagnosis will base it on 'scoring' a whole range of symptoms: hearing voices; thoughts not being one's own (thoughts removed or inserted, thought broadcasting); outside forces acting on body actions; delusional perception. Nowadays, most psychiatrists will base their diagnosis on assessing these different symptoms but, because there is no laboratory test, there is no certain way of proving the diagnosis.

HOW IT STARTS
Slowly - Schizophrenia often starts gradually in the middle and late teens. It is then hard to tell whether a gradual change in behaviour is a sign of mental illness or normal teenage rebellion. Because the changes are slow, parents often don't see that there is something wrong. And, because the behaviour of normal teenagers often changes, doctors too find it difficult to recognise the illness early on unless they happen to have known the person over the years and can see the change. If the teenage rebellion goes on for long and if the change in sleep patterns and mood swings is severe, watch for other signs such as muddled thinking, loss of friends and strange behaviour. Look out too for any sign of delusions or hallucinations or depression. If you suspect that a member of your family might have these symptoms and may be developing schizophrenia, get advice at once as the sooner the treatment can start, the less severe the illness is likely to be. When schizophrenia starts gradually, it is more difficult to treat and more likely to show distressing negative symptoms.

Suddenly - Some cases of schizophrenic illness start suddenly, sometimes after a shock or other stress such as childbirth, infection or exams. A person starts to hear voices, has delusions and a gamut of 'positive' symptoms. Your personality changes and you can't think straight. To the family and friends, the illness seems serious and distressing. Yet, there is often a complete and rapid recovery with treatment and a return to normal life.

In later life - Some people get schizophrenia late in life in their 60s or 70s. It is then more common in women, particularly those with poor hearing and living on their own. Symptoms include hearing voices and odd beliefs. The illness usually responds well to medical treatment. People with this schizophrenia can, with treatment, usually keep active and live normally in the community.

WHAT CAUSES SCHIZOPHRENIA?
Nobody knows its cause but there are a number of clues which are listed in Table 4. Heredity is known to play a part. Schizophrenia sometimes runs in families but it is not inherited in a simple way. If both a mother and father have schizophrenia, there is 1 chance in 2 that their child will get it. If only one parent has it, the chance that the child will develop it is 1 in 10. If one identical twin has it, the chance the other one will get it is 50:50. But identical twins have identical genes (the carriers of heredity) so if schizophrenia was due only to inheritance, we would expect that if one twin developed it the other would always do so too. The great advances made during the past 20 years in genetics and understanding how heredity works make this an exciting area in the search for the cause or causes of schizophrenia.

Abnormalities in the chemistry of the brain are also important. Individual brain cells communicate with one another by chemical messengers called neurotransmitters. Scientists have suggested that people with schizophrenia may produce too much of one of these transmitters, dopamine, and that this may explain the positive symptoms of the condition. This suggestion is based on two kinds of evidence: first, drugs that improve the positive symptoms of schizophrenia have in common the ability to lower dopamine levels in the brain; second, drugs such as amphetamine which stimulate dopamine transmission, produce symptoms similar to schizophrenia when taken persistently in large doses. It now seems that although dopamine transmission may be involved in some of the symptoms of schizophrenia, an abnormality in dopamine is not sufficient explanation of the disease. Nevertheless, research into the complex chemistry of the brain is an important way of gaining knowledge of schizophrenia. Biochemical explanations are not incompatible with genetic ones since the function and balance of the neurotransmitters is determined at least in part by heredity.

For many years, it has been suspected that there might be structural changes in the brains of patients with schizophrenia. However, the earlier methods of investigation did not reveal strong evidence to support the idea. Recent advances in methods of imaging the living brain have shown that there are subtle changes in the brains of many patients with schizophrenia. For example, slightly enlarged ventricles (the fluid-filled cavities in the brain) and a lessening of the normal asymmetry of the brain which, in humans, is slightly larger on one side. Such changes could be determined genetically or they might be the result of damage to the brain before or around the time of birth.

There are other environmental factors which might be implicated in causing schizophrenia. For instance, stress is widely recognised as one of the factors which appear to trigger off schizophrenic illness and may also cause relapses in an established illness.

There is no convincing evidence that other psychological factors such as distorted relationships within a family are able to bring about schizophrenic illness. Surveys have shown that people with schizophrenia have much the same family disagreements and differences as everyone else. Families are sometimes blamed for the schizophrenic illness of the children. There is no evidence to support such assertions, but it does appear that families can play an important part in preventing relapse by avoiding too much criticism, hostility towards or over-protection of the patient.

Although we still do not know what causes schizophrenia, we can conclude that it can be provoked. in genetically predisposed people, possibly by the effects of environmental disturbance, psychological stress or physical illness.

CAN SCHIZOPHRENIA BE PREVENTED?
We do not yet know enough about the causes to say how the illness can be prevented. However, one specific factor is important: drug abuse. Illicit drugs such as amphetamines, LSD, cocaine and cannabis can cause hallucinations and paranoid delusions similar to those found in schizophrenia. The psychotic effects of these drugs do not always clear up readily and there is some evidence that they may trigger a prolonged schizophrenic illness. In addition, such drugs can cause a relapse of an established illness. If you are concerned about drugs, discuss the problem with your doctor.

HOW SCHIZOPHRENIA IS TREATED
There is, as yet, no cure for schizophrenia but most sufferers improve with treatment especially if combined with psychosocial help. Medication in the form of antipsychotic drugs (also called the neuroleptics or major tranquillisers) is necessary to alleviate some of the disturbing symptoms. There is a large number of such drugs, many of them chemically related to each other. They are generally more successful at controlling the positive or florid symptoms than the negative symptoms although some drugs such as clozapine and risperidone also seem to be successful in some cases in reducing negative effects. Unfortunately, in addition to their therapeutic action, these drugs all have unwanted side-effects, in particular involuntary muscle movements and tics, facial grimaces and restlessness (see Table 5). The unwanted effects are sometimes so serious that doctors use other drugs to counteract them such as procyclidine or orphenadrine.

Clozapine is successful in improving some sufferers who do not respond to other antipsychotics or who have severe side-effects. In a small number of people, it reduces the ability to make the normal number of white blood cells which means the body cannot fight infections effectively. To make sure this is not happening, clozapine is only available to patients who have a blood test weekly for the first 18 weeks, then fortnightly and every four weeks after a year. Clozapine has few of the side-effects of the other antipsychotics, but the risk of damage to the blood-forming system means that it is mainly used where other drugs do not work or are unacceptable.

Two newer antipsychotics, risperidone (Risperdal) and sertindole (Serdolect), which are said to have some of the therapeutic features of clozapine, can be used without blood monitoring.

During 1997-8, three further "atypical" antipsychotics, olanzapine (Zyprexa), quetiapine (Seroquel) and ziprasidone, were introduced, although it is too early to say whether any of them will prove to be a major advance on what is currently available.

The establishment of a successful treatment for an individual suffering from schizophrenia is a difficult balancing act. The doctor is searching for a drug which will bring you the best quality of life. Different drugs may be more or less acceptable to you, depending on your own metabolism. The doctor will be looking for the minimum dose which will control the psychotic symptoms, but will not cause undesirable side-effects. The medications used for the treatment of psychotic illness are discussed in more detail in

There is no evidence that psychotherapy on its own has therapeutic value in the treatment of schizophrenia and other psychoses, but counselling and other forms of psychotherapy can help in dealing with problems associated with the illness.

DEALING WITH THE ILLNESS
Part of the problem is that the distressing symptoms of schizophrenia make it difficult for sufferers to communicate with those they love. They may involve their relatives in their persecutory symptoms, become difficult, antagonistic, abusive or even threatening towards them. During this time, it is very important that families and friends try to maintain as close a link as possible and remain patient and understanding no matter how strong the temptation is to become angry or resentful. In this respect, self-help groups run by voluntary organisations can be an invaluable source of support. There are several principles which families should try to follow.

EARLY DIAGNOSIS
When someone you know is preoccupied with bizarre thoughts, becomes emotionally withdrawn, has difficulty in thinking or shows a decline in performance and depression, you should get professional help since these signs may herald a schizophrenic breakdown (although they may be the symptoms of some other types of disturbance). Families are usually in the best position to notice these changes of behaviour and may be able to persuade the sufferer to seek early help. In these early stages, the sufferer is often aware that he is needing medical help and will be co-operative. But it is a difficult decision for the family. The fact that a son or daughter withdraws to a darkened room and refuses to eat, talk or emerge for days on end may be somewhat exaggerated adolescent behaviour done to cause aggravation and distress to the parents, or it may be the symptoms of the illness. However difficult it may be to accept, the family should not allow such a situation to drift but seek urgent help from the general practitioner. There is now an accumulation of evidence that the earlier the symptoms of schizophrenia are treated, the better the outcome.

Most general practitioners know relatively little about mental illness and will refer their patient to a consultant psychiatrist for diagnosis. The psychiatrist also faces difficult decisions. In the early stages of schizophrenia, the diagnosis may be uncertain because the full-blooded symptoms have not yet developed. Often the psychiatrist will want to give his patient the benefit of the doubt, although this may rebound on the sufferer and his family as the illness, if untreated, will often become much worse. The sufferer may, as a result, lose insight, be unaware that he is sick and unwilling to be treated.

SECOND OPINIONS
Schizophrenia is such a serious illness that most general practitioners will (wisely) refer suspected cases to a consultant psychiatrist and, however competent and experienced in mental illness the GP may be, it is best to ask for a referral. If you find yourself unsure of the psychiatrist's advice or diagnosis, you should seek a second opinion, either by telling the psychiatrist himself or (possibly more easily) the general practitioner who made the referral. If this proves difficult, telephone SANELINE (0845 767 8000) where one of our helpline volunteers should be able to help.

GOING TO HOSPITAL
The psychiatrist, after talking to you, may suggest that you go into hospital as a voluntary patient for more extensive assessment and possibly treatment. Usually, admission will be to the psychiatric department of an ordinary hospital or to a specialist psychiatric hospital. In either case, as a voluntary patient, you are entirely free to come and go as you please and can discharge yourself at any time.

If you are not willing to go to hospital voluntarily (or say that you are willing but past experience is that you will change your mind before admission), and provided you need hospital treatment in the interests of your own health or safety, or for the protection of other people, you may be admitted to hospital against your will. In order to safeguard your liberty, there are quite elaborate procedures for compulsory admission, which are laid down in the Mental Health Act (1983). These admissions are said to be 'under section" of the Act.

Compulsory detention in hospital is limited by the Act (unless renewed) to 28 days under Section 2 and 6 months under Section 3, although someone detained under section can (unless restricted by a court) have a section ended at any time by the "responsible medical officer" in the hospital. Most people who are ‘sectioned' are suffering from a psychotic illness, particularly schizophrenia. Once the illness has taken grip, it is common for the sufferer to be quite unaware that he is ill and, without intervention, his condition may decline further.

The nearest relative of someone suspected of mental illness has the legal right to request an assessment from an 'approved' social worker who is specially trained in mental health matters. The social worker will discuss frankly the family's fears and difficulties. Two doctors (one of them an expert in mental illness and one known to the patient) will carry out an examination. If they agree that there is a mental illness, the social worker will consider the balance between the individual's liberty and the consequence of not treating the illness. The fact that someone has been sectioned does not mean that his illness is worse or less likely to be controlled than that of other people. In fact, the reverse seems to be true, and those with the most florid symptoms often respond best to treatment.

TREATMENT IN HOSPITAL
The psychiatrist will usually try one or more treatments to see how well the you respond. His aim will be to reduce the level of medication until he has discovered the least dose required to control the symptoms which will also minimise side-effects. If side-effects prove troublesome, the doctor may try different medications since some suit individuals better than others. If side-effects are troublesome (see Table 5), you could discuss with the psychiatrist the possibility of trying one of the "atypical" antipsychotics which have recently come on the market. When the psychiatrist has completed his tests, he should keep you in hospital for some time to make certain the symptoms are checked and the illness stabilised. Unhappily, because of the shortage of beds in psychiatric hospitals (brought about by the unwise closure of many beds by the government) there may be pressures on you to leave hospital as soon as possible and sometimes patients are discharged before they are ready. Before leaving hospital, every patient should have a care plan set up and a key worker nominated.

BACK HOME AGAIN

When a patient is discharged from hospital, he will return home or to a hostel or flat often provided by the local authority. Those who have a family to return to are fortunate because there is someone to look after them. Parents should not blame themselves for their son's or daughter's illness. There was a theory years ago, now discredited, that "schizophrenogenic', over-concerned mothers caused the illness and sadly, a few remnants of these ideas are still current. Spouses may also feel very guilty when a husband or wife becomes schizophrenic. Again, there is no evidence that the illness is a consequence of dissatisfaction with the marital partner, although naturally the illness itself may place a great strain on the relationship. Equally, the sufferer should not be blamed for an illness which all the evidence suggests is outside his or her control.

MAKING THINGS NORMAL
Although many individuals may be left with residual difficulties after an acute attack of schizophrenia, life should be as normal as possible. Families should not fall into the trap of thinking that because someone has schizophrenia they are incapable of taking any decisions for themselves or of returning to lead a normal life. Moreover, the sufferer should be encouraged not to regard any slight deviation of behaviour as necessarily due to the illness without looking at the situation as a whole. Advice should be sought about employment, marriage, going abroad, childbirth and other areas of life so that appropriate plans can be made. Many of these normal activities may be made more difficult because of the stigma which surrounds mental illness. It is also sensible to preserve the expectation that someone with a schizophrenic illness should try to co-operate with others and to behave in a socially acceptable way. A vicious circle of over-protection and dependence on the part of the patient and carer can easily arise and should be avoided.

WATCHING FOR RELAPSE
Patients with schizophrenia are almost invariably required to continue to take a maintenance amount of medication even when they appear to have recovered and feel well. Most healthy people would find this requirement to take medication regularly, perhaps for years, difficult to comply with. For the schizophrenic person who may not be fully convinced that he is ill, it is doubly difficult especially as there may be unpleasant medication-induced side-effects. If friends or relatives discover that the patient is no longer taking medication in the prescribed way, they should alert the psychiatrist or key worker since failure to take antipsychotics may lead to a further schizophrenic breakdown.

Because it is difficult to remember to take tablets every day, many people are treated with a 'depot' injection of antipsychotic drugs, which is then gradually released into the bloodstream over a period of weeks. It is sometimes easier for a patient to attend for an injection every four weeks than to take tablets every day. Nevertheless, some patients miss their appointment for the next injection, and the family should help the medical and nursing staff to ensure that this does not happen.

PREVENTING RELAPSE
A major role of the family is to ensure that the sufferer does not become ill again. Although most relapses occur when the patient fails to take medication, there are other contributory causes: general health, drug abuse and life-style. There is some evidence that relapse is more frequent in families (or other carers) showing a high level of intrusive emotion and lessened where they are more tolerant and accepting. Stress, for example at work, may also trigger relapse.

Carers should be on the lookout for the tell-tale signs of returning psychosis and should alert the psychiatrist or key worker as soon as suspicions are aroused. Speed is essential because, if the returning illness is caught sufficiently early, it may be controlled by changing the dose of medication. But if it is left, it may quickly develop into a full-blown psychosis in which the sufferer becomes unaware that he is ill and will not co-operate.