Medically Reviewed On: May 07, 2008

MARTY MOSS-COANE: I'm Marty Moss-Coane. Welcome to our webcast. Schizophrenia is seen around the world, and it's a painful medical disorder which affects 1% of the population. The millions who have schizophrenia can be haunted with delusions, paranoias and hallucinations which prevent them from functioning and relating in the world. Before there was treatment, the diagnosis of schizophrenia was like a life sentence with no parole. Today there are treatment options and rehabilitation for people with schizophrenia, as well as support for patients and their families. How successful are these strategies in getting schizophrenics back on track? Joining us to discuss this top we have three guests. Nathaniel Lachenmeyer is the author of "The Outsider: A Journey of My Father's Struggle with Madness." His father, Charles, was a Ph.D. sociologist who eventually ended up homeless, diagnosed paranoid schizophrenic. The book he has written is about a son's coming to terms with his father's life. Nice to have you with us on our webcast.

NATHANIEL LACHENMEYER: Thank you.

MARTY MOSS-COANE: Joining us as well, Dr. Joseph Battaglia, clinical director of the Bronx Psychiatric Center. Nice to have you with us.

NATHANIEL LACHENMEYER: Thank you.

MARTY MOSS-COANE: And Dr. Anthony Salerno is with us as well, director of rehabilitation services at Rockland Psychiatric Center in New York. Nice to have you with us, as well.

ANTHONY SALERNO, PH.D.: Thank you.

MARTY MOSS-COANE: Dr. Battaglia, perhaps I'll begin with you. What is the common treatment for schizophrenia?

JOSEPH BATTAGLIA, MD: The mainstay has been medication. There have been some recent developments, but prior to the last 10 years, the mainstay was medications that blocked dopamine. What they would do was reduce hallucinations and delusions. But they didn't improve someone's cognitive abilities. They didn't improve their emotional feelings. If anything, dopamine is in the reward system, so if you block dopamine in someone, they actually feel less of a reward for something that would make you happy if you did it. There was a realization that just by reducing hallucinations and delusions didn't guarantee someone was going to get better.

The newer medications may improve, or at least don't make cognitive functions worse, but there's an appreciation now that that just brings them to be able to participate and get more from therapies. There's evidence to show that cognitive therapies are very helpful, vocational, reintegration with work, family therapies -- that the three combined actually give someone the best chance of continuing to do well.

MARTY MOSS-COANE: Let me turn to you, Dr. Salerno, about the rehabilitation process and what you find works with someone with schizophrenia.

ANTHONY SALERNO, PH.D.: One of the outcomes of schizophrenia is functional problems. Basic things in terms of living, learning and working and establishing relationships over time, and there is a deterioration in the person's skill level, so that we need a lot of opportunities to help a person learn, and to learn how to get along with others, learning the basics of managing one's environment, learning to get back to work, actually choosing a goal, the whole process of deciding on a direction in life, to find some meaning in life. Once this illness has occurred, it can be so disruptive to the original plans that a person had, and original goals. So how do you help somebody say, "Listen, I have these limitations, I have these problems, how do I fashion out and identify some goals that are realistic for me, and that also improve the quality of my life?" So that's what rehabilitation is all about.

But you need a lot more than helping people with skills. You also have to teach them and help them learn about their psychiatric condition, to learn about treatments, to learn about medications, to learn about how to use the mental health system to accomplish their own personal goals. Those are all the things -- a lot -- treatment, medication, skills, the supports, and having programs that offer people opportunities.

MARTY MOSS-COANE: Do you find you have to teach people to recognize when symptoms might return and then know what to do before it really becomes full-blown?

ANTHONY SALERNO, PH.D.: You've hit on a very, very important point. Learning the symptom management skills and stress management skills are extremely important. It would be nice, it would be wonderful is medication was the cure-all and it really did the trick, but it's not like that. An individual needs to put considerable effort and energy into managing their symptoms, and there are techniques and skills to cope more effectively, and that's a very important part of what practitioners need to do.

MARTY MOSS-COANE: Do you want to add to that, and then we'll talk a little bit about your father?

JOSEPH BATTAGLIA, MD: It was in the book that once someone starts to recover, they immediately go back to where they left off developmentally. So if they were in the midst of accomplishing something, they recover and they want to right away go back to school or go back to their job, and there is where therapy to say, "Okay, how can we plan this out," versus saying, "You can't do it" -- which isn't true -- versus setting them up for failure by not having the skills to manage stress. I think the book pointed that out very well.

NATHANIEL LACHENMEYER: My father was a sociologist who taught for many years, and after onset, it was interesting the way he was, on the one hand, incredibly grandiose and thought he was the center of a worldwide conspiracy, and also tried very practically and realistically to find teaching positions. He would have taken positions at any community college. Although he wasn't aware that he was ill, he was aware of how he was perceived, so his resumes were devoid of any hints of any kind of symptoms, any conspiracies, anything like that. So he would try to find work. I think that's very true. I think his goals and his ambitions were such that he was not able to be anything other than what he had been before onset. I think that was something he struggled with.

MARTY MOSS-COANE: So he stayed a college professor, or a Ph.D. professor his whole life.

NATHANIEL LACHENMEYER: In his head.

MARTY MOSS-COANE: In his mind.

NATHANIEL LACHENMEYER: Not by way of delusion, but that was his aspiration, and that was really the only work he was willing to consider. Looking at it from the interior perspective, the reason he kept at that one was because it's what defined him, clearly. But it's not just that. His delusional system was that that had all been taken away from him in an effort to control his sociological research, so it was also that he felt he was entitled to that.

MARTY MOSS-COANE: He resisted treatment. He was hospitalized several times, he was on mediation several times. Maybe I'm overstating that.

NATHANIEL LACHENMEYER: No, no. He resisted treatment, but it suggested a kind of willfulness that isn't there. In his case, he really -- I think there is a demographic element. There are people with schizophrenia who, as a feature of their disorder, aren't aware that they're ill, so he wasn't aware that he was ill. It really was as simple as that. He was aware of how he was perceived, he was aware he wasn't functioning where he had been. For example, in his case, although he tended not to comply with medication, he took every opportunity, every sort of vocational opportunity that was given to him within the hospital setting or in the community. That he would do and subject himself to, even though that meant nominally accepting the diagnosis of schizophrenia.

MARTY MOSS-COANE: I wonder how common that is. If you have a medication that works, I'm assuming the person begins to feel better, perhaps feels that they don't need the medication, and then you begin this cycle. Is that something that's common?

JOSEPH BATTAGLIA, MD: It's common not just in schizophrenia. If you look at diabetes, for instance, only one-third of people will adhere to their diabetic regimen over the course of a year. In schizophrenia, given the side effects -- weight gain or stiffness -- given that they don't completely make you feel better and given that you don't think you have that problem to begin with, and that even if you did take it there's still a chance, 30 to 40%, that you're going to have a relapse in a year, why would someone? It takes quite a bit of faith and having recovered and seeing what had happened to you to actually stick through it the next time it happens.

MARTY MOSS-COANE: There are side effects, are there not, to medication?

JOSEPH BATTAGLIA, MD: Right now there is a lot of effort going into developing those with less and less side effects, but there's weight gain -- you can gain 20% of your weight. You feel better, you look at yourself, you can't recognize who you are anymore.

NATHANIEL LACHENMEYER: Also -- I'm not sure about the newer medications, maybe -- but I know the older ones there was impotence and breasts developing. Has it changed?

ANTHONY SALERNO, PH.D.: Because of the prolactin hormone.

NATHANIEL LACHENMEYER: If you sort of map that onto a delusional system, it's quite frightening, I think, how that would be interpreted.

MARTY MOSS-COANE: I'm interested in what families need. We're talking about treatment, and if someone is connected to a family, it seems that the family is going to need a lot of support through this time.

ANTHONY SALERNO, PH.D.: They do, and fortunately, since really the 1980s, there have been major organizations that have been established with chapters all over the country and the world for families needing to be with other families and be able to share their experiences and to gain emotional support. They also need some accurate information about mental illness. Otherwise, you're left to your own devices to kind of interpret and project what you think is going on. So having patient practitioners being able to share with you what the latest information is about mental illness helps enormously. What some of the research also suggests is that learning problem-solving skills and how to negotiate the mental health system, which is a whole other set of problems that people face, those types of supports are very, very important. Also, how to communicate effective with someone who is ill. One of the things that we find is, we know what can make things worse: being very judgmental and very critical will make symptoms worse. But you can understand that. When you feel upset and feel very, very frustrated if the person doesn't take medication, the first thing is, "They don't want to get better," or "They're being defiant," or "They're disobedient," and that usually generates in us a clinical parent kind of response. So one of the things that people need to know is, the way you're feeling is not so bizarre. There are others who are going through it. That's the other thing: a sense of isolation, that no one else is really going through this. So those types of supports and those types of educational opportunities make an enormous difference for families.

MARTY MOSS-COANE: That makes me think about the community where your father actually ended up, in Burlington, Vermont. He was homeless there but well-known in that community. He was a well-known figure there, in fact, a panhandler on the street. He went to the diners. He had a bank account there. How important do you think that community was for your father?

NATHANIEL LACHENMEYER: At that point, he was homeless a year, the last year of his life, really, and it was the only social contact he had. One of the things that was interesting to discover just personally was that there were people who were able to look beyond the uniform of the homeless. He was covered in lice, he was the stereotypic image of a homeless person with the symptoms of schizophrenia, so he was talking to himself, gesturing, and there were many people who were able to look beyond that. No one saved his life, but they gave him coffee and cigarettes and things. But the most important thing, I think, is continuity. Since it's such a disruption of someone's life when they have this disorder, the more stable and continuous elements you can introduce, the better. For him in that period, he was able to give vent to his delusional system. He was able to talk to people. It wasn't cathartic, but it meant real contact, and I think that helps them feel not so disconnected.

MARTY MOSS-COANE: I have to say I was very touched. There was a bank security person there who dealt with your father quite a bit, and when you interviewed him, he shook your hand, and then you asked him if he shook your father's hand, and he did.

NATHANIEL LACHENMEYER: One of the symptoms of the disorder we haven't talked about is disorganized behavior, so he was filthy. He did, and there were many people who extended him, really, the same degree of courtesy and respect that you would anyone else, which is, frankly, miraculous. It's not something one can expect. To me, it's a very hopeful message about people's ability to look beyond stigma, and that if there can be a concerted effort on the part of the media to assist that, there will be a better understanding.

JOSEPH BATTAGLIA, MD: The point there is, what you get in the media is the sense of dangerousness that these people pose. What they don't say enough of is that chances are, if you have schizophrenia, there's a 10% chance you're going to die by suicide. Forty to 50% make attempts. Chances are you're going to be a victim of abuse. Chances are you're not going to get medical attention for illnesses that are treatable and die a premature death. To focus on those that have criminal histories misses the point. Of course, in working with families, learning how to -- They say strike when the iron's hot. Here you have to approach when the iron's cold. Wait until the emotions die down, which means the positive symptoms, wait until they're not active, because schizophrenia doesn't go on 24 hours a day. It ebbs and flows with the voices and delusions. That's how you approach someone to reduce the risk that they're going to show some aggression.

MARTY MOSS-COANE: I wanted to, since your father was homeless, all of us navigate through city streets and even into the suburbs. Are a fair percentage of the homeless schizophrenic, do you think? I'm looking at you, Dr. Salerno.

ANTHONY SALERNO, PH.D.: Yes. There have been different -- In terms of statistical studies, anywhere from 25% to 35%.

JOSEPH BATTAGLIA, MD: Divided between bipolar and schizophrenia.

ANTHONY SALERNO, PH.D.: One can understand how that can occur, even when there are available programs. Again, if the person doesn't think there's a problem, they don't want to adhere to different sorts of rules, or there's a preference, for whatever reason, there's a sense of greater safety out in the streets. So there are all sorts of factors that contribute to homelessness.

MARTY MOSS-COANE: Go ahead.

NATHANIEL LACHENMEYER: I was just to say that even, for example, in a homeless shelter that my father would have had access to during a severe winter in Vermont, he wouldn't shower as a function of his disorder. People said you could see the lice on him from 10 feet away, as a result of which he risked infecting the entire shelter, so he would up being the only homeless man on the street all winter. The point is that the people in the shelter were acting responsibly, but even in that setting, at that far end of the periphery of the spectrum, the people with schizophrenia are disadvantaged. In other words, he didn't want to be on the street. He had no choice as a result of his disorder.

MARTY MOSS-COANE: I do want to end on a positive note if I can. What I'm hearing, though, is that there is treatment, there is rehabilitation, there are support services, someone with schizophrenia can be helped and they do get better.

ANTHONY SALERNO, PH.D.: Absolutely.

MARTY MOSS-COANE: We are going to end on that note, and I think all three of you for joining us. Thank you very much. I'm Marty Moss-Coane, and thank you for joining us, as well.