Have you ever had one of those nights where you just couldn’t seem to fall asleep? While that happens to everyone every once in awhile, people with insomnia have to deal with these symptoms night after night. Some people with insomnia have trouble falling asleep, whereas others wake up throughout the night, and struggle to fall back asleep, and these disturbances typically happen at least 3 times each week.

Acute insomnia lasts less than a month, whereas chronic insomnia lasts over a month. Insomnia affects both the quantity and quality of sleep, which makes it hard for individuals to reach the restorative levels of sleep which causes daytime sleepiness and fatigue, and over time—feelings of irritability, anxiety, and depression.

This can lead to professional and personal problems, as well as day-to-day challenges like falling asleep while driving. Although insomnia can happen without an underlying cause, it can also accompany and worsen other problems like pulmonary diseases, psychiatric conditions, and a whole variety of conditions that might cause pain. Insomnia is also a common side effect of stimulants like caffeine, as well as depressants like alcohol, which can both disrupt the regular sleep cycle.

Finally, and probably most commonly, insomnia can be the result of daily stresses from work or relationships as well environmental factors such as having to work a night shift, or having a newborn baby. There are a number of biological factors associated with insomnia. Studies have shown that people with insomnia might have heightened levels of the stress hormone cortisol, which plays a role in the process of waking up every morning. People with insomnia are also more sensitive to the effects of cortisol, typically waking up at much lower levels of cortisol as compared to the general population. In addition, insomnia is also associated with reduced levels of estrogen and reduced levels of progesterone, which can happen during menopause.

Commonly, individuals with insomnia will self-medicate with alcohol and benzodiazepines, both of which can be extremely dangerous. Alcohol abuse can lead to a number of physical and psychological changes that can rapidly worsen the sleep-wake cycle and lead to dependence.

Similarly, benzodiazepines, especially short-acting ones, can also create dependence and have a high abuse potential, which can actually worsen insomnia if someone tries to stop using them.

One method of treatment is getting good sleep hygiene, which includes going to sleep and waking up at the same time every day including weekends, getting good exercise (but not right before bed), reducing alcohol intake, avoiding day-time naps, avoiding caffeine and smoking in the evening, and not going to sleep hungry.

Another potential treatment is stimulus control which includes using the bed only to sleep rather than a place from which to watch television, text, or talk on the phone. It also helps to keep the environment calm by removing bright lights like a computer or a phone screen, and minimizing noise.

Sometimes, though, these are unavoidable in which case eye covers and earplugs can definitely help. It’s also not helpful to try to force sleep to happen, which means that people that can’t sleep after 20 minutes should simply leave the bed and then return when they feel ready to sleep.

These suggestions help the individual associate sleep—and only sleep—with the bedroom. Also there’s behavior therapy, which includes relaxation techniques as well as cognitive behavior therapy to help better manage problems and life stressors. While these techniques are being used, some medications such as melatonin agonists, non-benzodiazepine sedatives, and occasionally benzodiazepines might be prescribed to help with sleep. These medications can often have side effects, though, so they are generally used for less than two months, usually in combination with the behavioral therapy techniques.

Alright so as a quick recap. Insomnia is an inability to get restorative sleep that causes daytime sleepiness and fatigue, and can be managed with good sleep hygiene, stimulus control, behavior therapy, and occasionally short courses of medications. Thanks for watching, you can help support us by donating on patreon, or subscribing to our channel, or telling your friends about us on social media.


Generalized anxiety disorder (GAD) – causes, symptoms & treatment


Say you’ve got a huge presentation in front of all your colleagues; you’re nervous, you’ve got quite a bit of stress leading up to the presentation. That stress is completely normal, and really—probably useful in certain situations since it can make you more alert and careful. After the presentation’s over you feel the stress start to fade away, right?

Well…for 3% of the population, the stress doesn’t go away, and maybe that stress isn’t even brought on by a specific event and is always just sort of always there. Either way, at this point it’s considered to be anxiety. That anxiety might even get worse over time, and causes things like chest pains or nightmares.

Sometimes the anxiety’s so severe that it causes someone to be anxious about leaving the house or doing everyday things, like going to work or school. This anxiety may be a sign of Generalized Anxiety Disorder, sometimes shortened to GAD. GAD’s characterized by excessive, persistent, and unreasonable anxiety about everyday things, like money, family, work, and relationships; even sometimes the thought of getting through the day causes anxiety.

If the anxiety’s persistent, then it doesn’t seem to go away, if it’s excessive, it’s usually more than someone else might feel, and if it’s unreasonable, they probably shouldn’t have a reason to feel anxious about it.

People who have GAD might even understand that their anxieties are excessive and unreasonable, but they feel it’s out of their control and don’t quite know how to stop it. People with severe GAD might be completely debilitated and have trouble with the simplest daily activities, or they might be only mildly affected and be able to function socially and hold down a job. Sometimes the feelings might worsen or improve over time. In addition to having feelings of worries and anxiety, other symptoms include edginess and restlessness, difficulty concentrating or feeling like the mind just goes blank, and also irritability.

These psychological symptoms can also lead to physical manifestations of symptoms like digestive problems from eating more or eating less. They might also have muscle aches and soreness from carrying tension in their muscles. Finally difficulty sleeping is a really common symptom that can have a serious impact on physical well-being, since the body’s not resting and can lead to issues of chronic fatigue. Although the decision that someone’s worry is excessive and unreasonable has a subjective quality, diagnosing GAD is aided by the diagnostic and statistical manual of mental disorders, or DSM-V, this manual gives a list of criteria to meet in order to be diagnosed with GAD.

First, the excessive worry and anxiety has to have been present for more days than not over the course of 6 months. In other words, a person should have the symptoms of excess or unreasonable worry on 90 or more days out of 180 days. Generally, people can’t quantify or track their feelings in that way, so again, this is meant to offer a general guideline, right?

Okay second—the person finds it hard to control their anxiety, meaning that they have a hard time calming themselves or “self-soothing” to help themselves regain control over their feelings.

Third, an adult must have three or more of the symptoms listed previously. In children though, typically defined as “school-age”, so between 6 and 18 years old, only one symptom is needed for the diagnosis of GAD.

Another criteria is that the anxiety causes impairment in important daily activities like school or work. For example, they might miss deadlines or find it difficult to even go to work because of their symptoms.

Fifth, the symptoms are not attributable to the physiologic effects of a drugs or medication, or due to a medical condition like hyperthyroidism which creates an excess of thyroid hormone, which can sometimes cause symptoms of anxiety and worry.

Finally, their anxiety isn’t better explained by another mental disorder like social phobia or panic disorder. Just like a lot of mental disorders, it’s unclear exactly why some individuals develop generalized anxiety disorder, but it’s thought to be a combination of genetic and environmental factors, as it seems to run in families.

It also has been shown to be twice as prevalent in females than in males. Treating GAD, like many mental disorders, may involve psychotherapy, medication, or a combination of the two. If it’s psychotherapy, cognitive behavior therapy has been effective since it teaches the patient to think and behave in different ways, and react differently to situations that would usually causes anxiety and worry.

Medications like benzodiazepines or antidepressants might be prescribed as well, benzodiazepines are a type of psychoactive drug that have a relaxing and calming effect. Antidepressants might also be prescribed, like selective serotonin reuptake inhibitors, or SSRIs, which regulate the serotonin levels in the brain and help elevate mood. Even though both medications and cognitive behavior therapy have similar effectiveness in the short-term, cognitive behavior therapy has major advantages over medication in the long term, due to unwanted effects of the medications like tolerance, dependence, and withdrawal.



You’ve probably come out of a particularly sad movie and said something like: “Man, that was depressing.”.

In this case, you’re talking about how, at that moment, the movie made you feel sad, discouraged, hopeless, or anxious. You probably wouldn’t say something like: “Man, that movie was clinically depressing.”

The latter expression refers to a much different state of depression. Clinical depression, which is sometimes called major depressive disorder or unipolar depression, is a serious mental disorder that has a lifetime incidence of up to 20% in women and 12% in men, making it one of the most common reasons people seek out mental health services. That being said, as well as being relatively common, clinical depression is, in fact, very serious.

It’s so serious that it interferes with someone’s day-to-day life, like working, studying, eating, and sleeping, essentially leading to this overall feeling that life isn’t enjoyable. But what causes someone to feel this way?

Well, we don’t exactly know what specifically causes clinical depression, especially since it can be so different between patients. It’s probably a combination of factors, though, like genetic factors, biological factors, environmental factors, and psychological factors. It’s been shown that people with family members who have depression are three times more likely to have it themselves, and this link seems to increase with how closely related family members are.

Biologically though, most medications focus specifically on neurotransmitters. Neurotransmitters are signalling molecules in the brain that are released by one neuron, and received by receptors of another neuron.

When that happens, essentially, a message is relayed from one neuron to the next. Regulation of how many of these neurotransmitters are being sent between neurons at any given time is thought to play a super important role in the development of symptoms of depression, since they’re likely involved in regulating a lot of brain functions, like mood, attention, sleep, appetite, and cognition. The three main neurotransmitters that we focus on for depression are serotonin, norepinephrine, and dopamine.

Why do we focus on these three?

Well, because medications that cause there to be more of these neurotransmitters in the synaptic cleft, the space between the neurons, are shown to be effective antidepressants. And this finding lead researchers to develop the monoamine-deficiency theory, which says that the underlying basis of depression is low levels of serotonin, norepinephrine, or dopamine, which are all called monoamines, because they have one amine group.

Additionally, it’s thought that each of these might have an impact on certain sets of symptoms with depression, like norepinephrine on anxiety or attention, or serotonin on obsessions and compulsions, or dopamine on attention, motivation, and pleasure. So, if one of these is down, then that could lead to a set of specific symptoms being felt by the patient.

Serotonin, in particular, is thought to be a major player. Some theories suggest it’s even capable of regulating the other neurotransmitter systems, although evidence supporting this theory is still pretty limited. Some hard evidence implicating serotonin in depression has to do with tryptophan depletion, which is the amino acid the body uses to make serotonin.

So, if you take it away, you can’t make as much serotonin, and it’s been shown that when the body can’t make as much serotonin, patients start getting symptoms of depression. So that’s all well and good but, unfortunately, the reasons why serotonin, or other neurotransmitters, might be lost or decreased in depressed patients in the first place isn’t well known, and research remains ongoing.

Ultimately, development of depression is complicated, right? It involves these biological components in combination with the genetic components, as well as environmental factors, which could be specific events like a death or a loss, or sexual and physical abuse. In order to diagnose clinical depression, patients must meet certain criteria that are outlined in the Diagnostic and Statistical Manual of Mental Disorders, the fifth edition.

First they must first be affected by at least 5 of the following 9 symptoms most of the day, nearly every day: depressed mood, diminished interest or pleasure in activities, significant weight loss or gain, inability to sleep or oversleeping, psychomotor agitation, like pacing or wringing one’s hands, or psychomotor impairment, like, this overall slowing of thought and movements, fatigue, feelings of worthlessness or guilt, lowered ability to think or concentrate, and, finally, recurrent thoughts of death, or suicidality, including suicidal thoughts, with or without a specific plan, as well as suicide attempts.

And these symptoms must cause significant distress in the patient’s daily life. Also, the depressive episode can’t be due to a substance or other medical condition, the symptoms can’t be better explained by another mental disorder, like schizoaffective disorder and, finally, the patient can’t have had a manic, or hypomanic, episode, at any point. Additionally, sometimes major depressive disorder can be divided into subtypes, or closely-related conditions.

Postpartum depression is a subtype that can happen following childbirth, although studies have shown that, in many cases, onset of depression occurs prior to childbirth as well, so it’s now diagnosed as depressive disorder with peripartum onset, in other words, the onset happens during pregnancy, or four weeks following delivery.

It’s not quite understood why this happens, although hormonal changes likely play a role, especially oestrogen and progesterone. Also though, an abrupt change in lifestyle might be an important causal factor, especially because this can happen in men, as well as women. Atypical depression is another important subtype that’s characterised by an improved mood when exposed to pleasurable or positive events, called mood reactivity. And this is in contrast to other subtypes like melancholic depression, even during what used to be pleasurable events.

Also, atypical depression often includes symptoms like weight gain or increased appetite, oversleeping, heavy-feeling limbs, also known as leaden paralysis, and rejection sensitivity, essentially, feeling anxiety at the slightest evidence of rejection. Finally, dysthymia, now known as persistent depressive disorder, is sometimes used to describe milder symptoms of depression that happen over longer periods of time, specifically, two or more years with two or more of the following symptoms: a change in appetite, a change in sleep, fatigue or low energy, reduced self-esteem, decreased concentration or difficulty making decisions, and feelings of hopelessness or pessimism.

Knowing that so many factors are probably involved in depression, it can be a challenge to treat, although, with the right treatment, 70-80% of patients with clinical depression can significantly reduce their symptoms. Treatment can come in many forms, and are most commonly grouped into one of two major categories: one, non-pharmacologic approaches, in other words, things other than medications, and two, pharmacologic approaches, either a single medication or combinations of medications.

Starting with a non-medication approach, a number of studies have shown the benefits of physical activity in helping with depression. There are various reasons why it’s thought to work, ranging from the release of neurotransmitters, endorphins, and endocannabinoids, to raising the body temperature and relaxing tense muscles. Regardless of the exact mechanisms, data suggests that exercising for 20 minutes, three times a week can help alleviate depression symptoms.

There’s also a lot of research exploring the relationship between diet and depression, and although there are no “silver bullet” foods, many experts suggest healthy eating habits, like more fruits and veggies. Beyond physical activity and healthy eating, which is more helpful for a number of reasons, another major non-pharmacologic approach is psychotherapy, or “talk therapy”, which is definitely preferred for young patients and for those with milder symptoms.

There are a few popular approaches including cognitive behavioural therapy and interpersonal therapy, and the most important thing here is that these approaches depend heavily on the relationship between the patient and the therapist, as well as the clinical skills of the therapist.

If patients have more severe depression, or mild depression for a long period of time, then antidepressant medication might be prescribed along with the therapy. The most commonly prescribed medications are selective serotonin re-uptake inhibitors, or SSRIs. In the synaptic cleft, after neurotransmitters get released, those neurotransmitters are normally reabsorbed. SSRIs block the reabsorption, or inhibit the reuptake, of serotonin, which means that there’s going to be more serotonin in the synaptic cleft. Other classes of antidepressants that are less commonly prescribed are monoamine oxidase inhibitors, or MAOIs, and tricyclics.

As a final, last-line treatment for severe depression, ECT might be performed, under written consent. ECT stands for electroconvulsive therapy, and is when a small and controlled amount of electric current is passed through the brain while patients are under general anaesthesia, and this induces a brief seizure. Although ECT’s been used for decades, and actually does seem to be effective for about 50% of patients, the reason why electrically-induced seizures seem to improve symptoms is not well understood. Alright, clinical depression is tough right? Both for those experiencing it and for those trying to help treat it. Unlike many other illnesses, depression carries with it a lot of social stigma and can lead to moral judgements that can make a person with depression feel even worse.

Schizoaffective Disorder

Schizoaffective disorder is characterized by persistent symptoms of psychosis resembling schizophrenia with additional periodic symptoms of mood (or affective) disorders.

Symptoms of Schizoaffective Disorder

The following are symtpoms that a person with Schizoaffective Disorder can experience.

Symptoms of depression:

  • Feel constantly sad and fatigued
  • Have lost interest in everyday activities
  • Are indecisive and unable to concentrate
  • Sleep and eat too little or too much
  • Complain of various physical symptoms
  • May have recurrent thoughts of death and suicide

Symptoms of mania:

  • Suffering from sleeplessness
  • Compulsively talkative
  • Agitated and distractible
  • Convinced of their own inflated importance
  • Susceptible to buying sprees
  • Prone to cheerfulness turning to irritability
  • Indiscreet sexual advances, and foolish investments
  • Paranoia, and rage

Symptoms of psychosis:

  • Hearing or seeing things that aren’t there
  • Bizarre thinking
  • Difficulty with emotions or appearing apathetic
  • Changes in speech
  • Have confused thinking
  • Paranoia 
  • Strange or out of character behavior
  • And inappropriate emotional reactions

Schizoaffective disorder is a combination of two mental illnesses – schizophrenia and a mood disorder. 

The main types of associated mood disorder include bipolar disorder (characterised by manic episodes or an alternation of manic and depressive episodes) and unipolar disorder (characterised by depressive episodes).

Schizoaffective disorder is classified into two subtypes: schizoaffective bipolar type and schizoaffective depressive type. Mental health professionals currently believe that schizoaffective disorder is a kind of schizophrenia. 

Estimates suggest that as many as one in three people diagnosed with schizophrenia actually have schizoaffective disorder. Diagnosis can be difficult because the symptoms of schizoaffective disorder are so similar to that of schizophrenia and bipolar disorder.

Symptoms of schizoaffective disorder

The symptoms of schizoaffective disorder can include:

  • psychotic symptoms – losing touch with reality, hallucinations, delusions, disorganised thoughts, chaotic speech and behaviour, anxiety, apathy, blank facial expression, inability to move
  • manic symptoms – increased social, sexual and work activity, rapid thoughts and speech, exaggerated self-esteem, reduced need for sleep, risky behaviours, impulsive behaviours such as spending sprees, quick changes between mood states such as happiness to anger
  • depressive symptoms – loss of motivation and interest, fatigue, concentration difficulties, physical complaints such as headache or stomach ache, low self-esteem, suicidal thoughts, loss of appetite, insomnia.

The cause of schizoaffective disorder is unknown

Most mental health experts believe that schizoaffective disorder is a variation of schizophrenia, but the exact cause remains unclear. Current theory suggests that schizoaffective disorder is triggered by a range of factors working in combination including: 

  • genetic susceptibility
  • environmental factors such as stress
  • differences in brain chemical (neurotransmitters) and receptor interactions.

Diagnosis of schizoaffective disorder is difficult

Diagnosis is difficult because the symptoms of schizoaffective disorder are similar to bipolar disorder and schizophrenia. For example, people who are severely depressed can sometimes suffer from hallucinations, while people coming out of acute schizophrenic episodes are prone to depression (post-psychotic depression). A long term history of the person is necessary to confirm the diagnosis.

The symptoms of mania can easily be confused with the emotions, thoughts and behaviours commonly experienced during a schizophrenic psychotic episode. 

Diagnosis may take some time because it is so difficult to tell the difference between schizoaffective disorder, schizophrenia and mood disorders. Usually, a diagnosis of schizoaffective disorder is made when the symptoms of schizophrenia and the symptoms of a mood disorder (such as bipolar disorder or unipolar disorder) are present at the same time for at least two weeks.

Diagnosis methods for schizoaffective disorder

Medical tests may include x-rays and blood tests to make sure the symptoms aren’t caused by physical disease. Factors common to schizoaffective disorder that may help a diagnosis include: 

  • onset is typically during the years of early adulthood
  • watching a moving object is usually difficult for a person with schizoaffective disorder
  • rapid eye movement (REM) sleep usually occurs abnormally early
  • women are more susceptible than men.

Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression.

Reading NAMI’s content on schizophrenia and bipolar disorder will offer many overlapping resources for schizoaffective disorder. Because schizoaffective disorder is less well-studied than the other two conditions, many interventions are borrowed from their treatment approaches.

Many people with schizoaffective disorder are often incorrectly diagnosed at first with bipolar disorder or schizophrenia because it shares symptoms of multiple mental health conditions.

Schizoaffective disorder is seen in about 0.3% of the population. Men and women experience schizoaffective disorder at the same rate, but men often develop the illness at an earlier age. Schizoaffective disorder can be managed effectively with medication and therapy. Co-occurring substance use disorders are a serious risk and require integrated treatment.


The symptoms of schizoaffective disorder can be severe and need to be monitored closely. Depending on the type of mood disorder diagnosed, depression or bipolar disorder, people will experience different symptoms:

  • Hallucinations, which are seeing or hearing things that aren’t there.
  • Delusions, which are false, fixed beliefs that are held regardless of contradictory evidence.
  • Disorganized thinking. A person may switch very quickly from one topic to another or provide answers that are completely unrelated.
  • Depressed mood. If a person has been diagnosed with schizoaffective disorder depressive type they will experience feelings of sadness, emptiness, feelings of worthlessness or other symptoms of depression.
  • Manic behavior. If a person has been diagnosed with schizoaffective disorder: bipolar type they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania.


The exact cause of schizoaffective disorder is unknown. A combination of causes may contribute to the development of schizoaffective disorder.

  • Genetics. Schizoaffective disorder tends to run in families. This does not mean that if a relative has an illness, you will absolutely get it. But it does mean that there is a greater chance of you developing the illness.
  • Brain chemistry and structure. Brain function and structure may be different in ways that science is only beginning to understand. Brain scans are helping to advance research in this area.
  • Stress. Stressful events such as a death in the family, end of a marriage or loss of a job can trigger symptoms or an onset of the illness.
  • Drug use. Psychoactive drugs such as LSD have been linked to the development of schizoaffective disorder.


Schizoaffective disorder can be difficult to diagnose because it has symptoms of both schizophrenia and either depression or bipolar disorder. There are two major types of schizoaffective disorder: bipolar type and depressive type. To be diagnosed with schizoaffective disorder a person must have the following symptoms.

  • A period during which there is a major mood disorder, either depression or mania, that occurs at the same time that symptoms of schizophrenia are present.
  • Delusions or hallucinations for two or more weeks in the absence of a major mood episode.
  • Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the illness.
  • The abuse of drugs or a medication are not responsible for the symptoms.



Schizophrenia – causes, symptoms, diagnosis, treatment & pathology


Schizo means split, and phrenia, in this case refers to the mind.

Even though schizophrenia can be interpreted to mean “splitting of the mind”, it does not refer to a split personality, like some media sources might portray, but rather schizophrenia describes a scattered or fragmented pattern of thinking.

Schizophrenia’s actually a syndrome, meaning there’re all sorts of symptoms that might be associated with it and different patients might experience different symptoms, although the symptoms can be broadly categorized into three major areas: positive symptoms, negative symptoms, and cognitive symptoms.

Alright taking a step back, most human symptoms from any illness are extreme versions of a normal physiologic process (for example everyone has a heartbeat and tachycardia is a fast heartbeat, everyone has a normal body temperature, but during a fever that temperature is higher). In schizophrenia, patients have positive symptoms which aren’t positive in the sense that they’re helpful, but positive in the sense that they’re some new feature that doesn’t have some “normal” or physiologic counterpart.

These are the psychotic symptoms, so delusions, hallucinations, disorganized speech, and disorganized or catatonic behavior; none of which occur physiologically.

Delusions are false beliefs that the patient might feel very strongly about, so much so that they won’t change their mind, even if you give them evidence against it. There are all sorts of different delusions, like, for example, a delusion of control, where somebody thinks that some outside force or person or thing is controlling their actions.

They could also be delusions of reference, where someone might think that insignificant remarks are directed at them, like a newscaster is speaking directly to them through the TV. Hallucinations are a second type of positive symptom, and can be any kind of sensation that’s not actually there, including visual but also including auditory sensations, like hearing voices or commands.

A third type is disorganized speech An example being something like a “word salad”, which seems like just a random jumbling of words or phrases, like “pencil dog hat coffee blue”.

Disorganized behavior on the other hand could be like if they exhibit bizarre or silly behavior that’s out of context and doesn’t seem to have much of a purpose, like for example wearing multiple layers of jackets on a hot summer day. Also sometimes the behavior is described as “catatonic”, which has to do with their movements, posture, and responsiveness.

So like they might be super resistant to moving, or be in an unresponsive stupor. Negative symptoms, are like when there’s this reduction or removal of normal processes, and this is like a decrease in emotions they can express, or a loss of interest in things they once found interesting.

One type of a negative symptom is called flat affect, where they don’t respond with an emotion or reaction that would seem appropriate, like if they saw something very unexpected like a small monkey playing in their living room, they might simply sit and watch idly as if nothing was happening.

Another type is alogia, or poverty of speech, which is a lack of content in speech, so like if somebody asked them “do you have any children?”, they might respond with “yes”, instead of “yes, one boy and two girls”.

A third type of negative symptom is avolition, which is this decrease in motivation to complete certain goals, so someone might stay at home for long periods of time, without trying to reach out to friends or find work. Cognitive symptoms include things like not being able to remember things, learn new things, or understand others easily. These symptoms are more subtle though, and more difficult to notice and might only be detected if they have really specific tests performed. An example might be somebody not being able to keep track of several things at once, like a phone number and an address. People with schizophrenia seem to cycle through three phases, typically in order. During the prodromal phase, patients might become withdrawn and spend most of their time alone, and often this seems similar to other mental disorders like depression or anxiety disorders. During the active phase, patients experience more severe symptoms like delusions, hallucinations, disorganized speech, disorganized behavior, or catatonic behavior. Following an active phase, patients often enter into a residual phase, where they might exhibit cognitive symptoms like not being able to concentrate or becoming withdrawn again, as with the prodromal phase.

For an official diagnosis of schizophrenia, patients need to be diagnosed with two of the following symptoms—Delusions, hallucinations, disorganized speech, disorganized behavior or catatonic behavior, or negative symptoms, and at least one of them has to be either delusions, hallucinations, or disorganized speech, So basically they couldn’t have just disorganized behavior and negative symptoms. Even though some patients have cognitive symptoms as well, they aren’t specifically needed for a diagnosis. Also though, for a diagnosis, signs of these disturbances must be ongoing for at least 6 months, meaning they’re likely in one phase or another for 6 months, but there must be at least one month of active-phase symptoms. And finally, those symptoms can’t be attributable to another condition, like substance abuse.

Now that we’ve diagnosed it…why does it even happen in the first place? What causes schizophrenia? Well we don’t really know, since it seems like the signs and symptoms of schizophrenia are pretty unique to humans, or at least they’re hard to imagine or notice in animal models like mice or rats.

One clue is that the majority of antipsychotic medications that improve schizophrenia symptoms block the dopamine receptor D2, which reduces dopamine levels in neurons.

This suggests that maybe schizophrenia has something to do with increased levels of dopamine.

These medications, though, are neither universally nor completely effective, and don’t work for everyone with schizophrenia, which adds to the confusion and means there’s probably more to it than just the D2 receptors.

Interestingly, one of the most effective antipsychotic drugs, clozapine, is a weak D2 antagonist, suggesting that other neurotransmitter systems like norepinephrine, serotonin, and GABA are involved.

Twin studies have shown support for a genetic basis as well, even though there haven’t been any specific genes conclusively linked to schizophrenia yet.

Also, environmental factors, like early or prenatal exposure to infection, and certain autoimmune disorders like celiac disease have been linked with schizophrenia.

Finally, another important set of clues involves the epidemiology, schizophrenia seems to happen slightly more in men than women, with onset in the mid-twenties for men but late-twenties for women; and the clinical signs of schizophrenia are often less severe.

Some studies suggest this difference might be due to an estrogen regulation of dopamine systems. There doesn’t, however, seem to be any differences among race.

Now treating schizophrenia can be really tricky, and antipsychotic medications are often used, but it’s super important to combine the efforts of several clinicians and health professionals, including professionals in therapy or counseling, medicine, and psychopharmacology.

Antipsychotics can be very effective at reducing symptoms, but they often come a lot of additional considerations to keep in mind, like cost and the potential for unwanted side effects like tolerance, dependence, and withdrawal.



It’s perhaps the most stigmatized and misunderstood psychological disorder of them all, even among psychologists.

Maybe because it’s pretty rare, affecting about 1% of the population, schizophrenia causes more anxiety in the media, in the public, and even in doctors offices than any other mental illness.

As a result, its sufferers have often been shunned, abused, or locked up. And among the many fallacies that surround the disorder is simply what it means.

The word “schizophrenia” literally means “split mind” but contrary to popular belief, the condition has nothing to do with a split in personality or multiple personalities.

The term refers instead to what’s sometimes called a “split from reality.”

Multiple Personality Disorder, now known as Dissociative Identity Disorder, is a totally different type of condition, a kind of dissociative disorder.

And these too, are shrouded in misconceptions, partly because they were the subject of, probably, the greatest psychological hoax of all time.

While many of us can relate on some level to the emotional swings, nervousness, and compulsions that come with mood and anxiety disorders, it can be a lot harder for those without direct experience to relate to the symptoms of schizophrenia and dissociation.

Unfortunately we tend to fear and avoid what we don’t understand in each other, whether it’s a friend of family member or just some stranger on the bus.

But thankfully part of the psychologist’s job is to demystify the things that can happen in our heads, and as is often the case, understanding may be the key to compassion.

Schizophrenia is a chronic condition that usually surfaces for men in their early to mid-20s, and for women in their late 20s.

For some the disorder comes on gradually, but for others it could arise more suddenly, perhaps triggered by stress or trauma, although no event can actually cause the disorder.

Once thought of as a single discrete condition, schizophrenia is now included in the DSM-5 as a point on a spectrum of disorders that vary in how they’re expressed and how long they last, but they share similar symptoms.

Schizophrenia Spectrum Disorders are currently thought of as characterized by disorganized thinking; emotions and behaviors that are often incongruent with their situations; and disturbed perceptions, including delusions and hallucinations.

They all involve a kind of loss of contact with reality on some level. The resulting behaviors and mental states associated with this break from reality are generally called “psychotic symptoms” and they usually impair the ability to function.

When someone’s experiencing psychotic symptoms, their thinking and speech can become disorganized, rambling and fragmented.

This tendency to pick up one train of thought and suddenly switch to another and then another can make communication painfully difficult. People exhibiting these symptoms can also suffer a breakdown in selective attention, losing the ability to focus on one thing while filtering others out.

In extreme cases, speech may become so fragmented it becomes little more than a string of meaningless words, a condition given a name that sounds like its own kind of non sequitur.

Classic schizophrenia is also often marked by delusions or false beliefs not based in reality. These delusions can be rooted in ideas of grandeur like “I’m the queen of England!” or “I won an Olympic gold medal for the luge!”

Or they can become narratives of persecution and paranoia, believing your thoughts and actions are being controlled by an outside force or that you’re being spied on or followed or that you’re on the verge of a major catastrophe.

And there are some complicated variations on these delusions, like feeling that you’ve died or don’t exist anymore or that someone is madly in love with you or that you’re infested with parasites.

Delusions of one kind of another strike as many as four out of five people with schizophrenia. While some delusions can seem fairly logical, they can also be severe and bizarre and frightening.

Unfortunately maybe the most memorable examples of people suffering from severe delusions come from serial killers and yeah, while Son of Sam did claim that he was taking orders from his neighbor’s dog, that kind of stuff is in the tiny, tiny, tiny minority.

Brian Wilson of The Beach Boys and Syd Barrett of Pink Floyd both suffered psychotic symptoms.

And then of course there’s John Nash, the Nobel Prize winning American mathematician and subject of the movie “A Beautiful Mind.” Through proper treatment, some people with schizophrenia have not only learned to live with their illness but also made fantastic creative contributions to the world.

Maybe people with schizophrenia also suffer from perceptual disturbances, or sensory experiences that come without any apparent sensory stimulation, like hallucinations. This is when a person sees or hears something that isn’t there, often lacking the ability to understand what is real and what isn’t.

Auditory hallucinations, or hearing voices, are the most common form, and these voices are often abusive. It’s as if you’re inner monologue, that conversation that you have with yourself or the random things that float through your head, were somehow coming from outside of you.

It’s as if you couldn’t sort out whether the voices in your mind were internal and self-generated, or external and other-generated. To me, it sounds terrifying.

Other common symptoms include disorganized, abnormal, or incongruent behavior and emotions. This could mean laughing when recalling a loved one’s death or crying while others are laughing.

Acting like a goofy child one minute, then becoming unpredictably angry or agitated the next. Movements may become inappropriate and compulsive, like continually rocking back and forth or remaining motionless for hours.

Broadly, most psychotic symptoms fall into three general categories traditionally used by psychologists: positive, negative, and disorganized symptoms.

Positive symptoms are not what they sound like. They’re the type that add something to the experience of the patient. Like, for example, hallucinations or inappropriate laughter or tears or delusional thoughts.

Negative symptoms refer to those that subtract from normal behavior, like a reduced ability to function, neglect of personal hygiene, lack of emotion, toneless voice, expressionless face, or withdrawal from family and friends. Finally, disorganized symptoms are those jumbles of thought or speech that could include word salad and other problems with attention and organization.

Symptoms like these are useful in diagnosing a disorder on the schizophrenia spectrum, but there’s a physiological component too. Like many of the disorders we’ve talked about, schizophrenia has been associated with a number of brain abnormalities.

Post mortem research on schizophrenia patients has found that many have extra receptors for dopamine, a neurotransmitter involved in emotion regulation and the brain’s pleasure and reward centers.

Some researchers think that overly responsive dopamine systems might magnify brain activity in some way, perhaps creating hallucinations and other so-called positive symptoms as the brain loses its capacity to tell the difference between internal and external stimuli.

For this reason, dopamine blocking drugs are often used as anti-psychotic medications in treatment. Modern neuroimaging studies also show that some people with schizophrenia have abnormal brain activity in several different parts of the brain. One study noted that when patients were hallucinating, for example, there was unusually high activity in the thalamus, which is involved in filtering incoming sensory signals.

Another study noted that patients with paranoid symptoms showed over-activity in the fear processing amygdala. So, schizophrenia seems to involve not just problems with one part of the brain, but abnormalities in several areas and their interconnections. But what might be causing these abnormalities? Earlier I mentioned how a stressful event might trigger psychotic symptoms for the first time, even though it can’t actually create the disorder.

Psychologists call this the “diathesis-stress model.” This way of thinking involves a combination of biological and genetic vulnerabilities — diathesis — and environmental stressors — stress — that both contribute to the onset of schizophrenia.

The Theory

The diatheses stress model is one of several theories used over decades to try to understand and explain the complexities of psychological illnesses such as schizophrenia and depression. This model believes that people develop a psychological disorder in response to stress because they have an underlying predisposition to the disease.

This underlying vulnerability (diathesis) comes from genetics, or biologic predisposing factors. Environmental stresses interact with the diathesis to trigger a psychological disease in a person.

In this theory, neither predisposition nor stress alone can trigger mental illness, rather, stress triggers the diathesis and both interact in some way to manifest the disease state. The more vulnerable a person is and the lower his threshold, the less stress it takes to trigger a disorder.

Individual Variation

Vulnerability explains why one person may develop depression or a major psychiatric disorder while another does not, even though they encounter the same stress. Because the level of diathesis and resilience varies from one person to the other, people vary in how they respond.

The Predisposition

The diathesis or vulnerability to a psychological disorder lies quiet until a person encounters stresses in his environment. Diathesis factors can include:

  • Genetics, such as having a family history of a psychological disorder that might be related defective genes
  • Biologic, such as oxygen deprivation at birth or poor nutrition during early childhood
  • Childhood experiences, such as isolation, loneliness or shyness that creates a distorted view of the world

Part of the theory is that everyone has a certain level of vulnerability and a certain threshold for a stress to trigger disease. The more vulnerable you are and the lower your threshold, the more likely that a mental disorder will manifest.

Stress Factors

Stress factors that can interact with a person’s predisposition for psychological disease can range from mild to major stressors and include:

  • Minor daily stress in home or external environment
  • Life events such as a family death, a divorce, starting school
  • Short-term factors such as a school or a work assignment
  • Long-term stress such as chronic pain or an ongoing illness

This model helps explain why some people with genetic vulnerability might not always develop schizophrenia and why the rates of schizophrenia tend to be higher with some degree of poverty or socioeconomic stress.

And it seems too that there is some kind of genetic predisposition for the disorder. The one-in-a-hundred odds of developing schizophrenia jumped to nearly one in ten if you have a parent or sibling with the disorder, with about 50/50 odds if that sibling is an identical twin, even if those twins were raised apart.

One recent landmark seven year study looked at genetic samples across 35 countries, examining more than 35,000 people with schizophrenia, and another 110,000 without the disorder.

The study identified more than 100 genes that may increase the risk of schizophrenia. As expected, some of these genes involve dopamine regulation, but others are related to immune system functioning.

Researchers continue to tease out what is exactly going on here, but many are hopeful that these new findings will lead to better treatment. Clearly, schizophrenia is a challenging disorder to live with and one that’s hard for outsiders to understand, but maybe even more rare and more elusive are the dissociative disorders.

These are disorders of consciousness, called dissociative because they’re marked by an interruption in conscious awareness.

Patients can become separated from the thoughts or feelings that they used to have, which can result in a sudden loss of memory or even change in identity. Now, we might all experience minor dissociation at times, like maybe the sense that you’re watching yourself from above, as in a movie, or like you’re driving home and get so zoned out that suddenly you find yourself in front of Taco Bell thinking, like, “How did I get here?”.

Those things would generally fall into the normal range of dissociation, but most of us don’t develop different personalities. Dissociative disorders come in several different forms, but the most infamous of the bunch is probably Dissociative Identity Disorder.

This has long been known as Multiple Personality Disorder and, yes, it is a thing. It’s a rare and flashy disorder in which a person exhibits two or more distinct and alternating identities and the best known case was that of Shirley Mason, whose story was famously rendered in the 1973 best seller “Sybil” and later in a popular mini-series.

The book was marketed as the true story of a woman who suffered great childhood trauma and ended up with 16 different personalities, ranging from Vicky, a selfish French Woman, to handyman Syd, to the religious and critical Clara.

The book became a craze and within a few years reported cases of multiple personality skyrocketed from scarcely 100 to nearly 40,000. Many believe the book was essentially responsible for creating a new psychiatric diagnosis.

It turns out though, Sybil’s story was a big fat lie. Yes, Shirley Mason was a real person and one with a troubled, traumatic past and a number of psychological issues. As a student in New York in the 1950s she started seeing a therapist named Connie Wilbur and taking some heavy medications.

And somewhere in there, maybe because she was coaxed, or maybe because she wanted more attention, Shirley started expressing different personalities.

Dr. Wilbur built a career and a book deal out of her star patient, even after Shirley confessed that her split personality was a ruse. The Sybil case is a powerful reminder that we really don’t understand dissociative disorders very well or even know if they’re always real.

Indeed, some people question if. Dissociative Identity Disorder is an actual disorder at all. But some studies have shown distinct body and brain states that seem to appear in different identities, things like one personality being right handed while the other is left handed, or different personalities having variations in their eye sight that ophthalmologists could actually detect.

In these cases, dissociations of identity may be in response to stress or anxiety, a sort of extreme coping mechanism. Either way, the debate and the research continue.

Today we talked about the major symptoms associated with the schizophrenia spectrum disorders, including disorganized thinking, inappropriate emotions and behaviors, and disturbed perceptions.

We also discussed brain activity associated with these disorders and talked about their possible origins including the diathesis stress model. You also learned about dissociative disorders, and Dissociative Identity Disorder in particular, and the scandal that was the Sybil case.

Depersonalization / Derealization Disorder Symptoms

The person has persistent or recurrent experiences (episodes) of feeling detached from one’s surroundings, mental processes, or body (e.g., feeling like one is in a dream, or as if one is looking at themselves as an outside observer).

In the case of depersonalization, the individual may feel detached from his or her entire being (e.g., “I am no one,” “I have no self”). He or she may also feel subjectively detached from aspects of the self, including feelings (e.g., hypoemotionality: “I know I have feelings but I don’t feel them”), thoughts (e.g., “My thoughts don’t feel like my own,” “head filled with cotton”), whole body or body parts, or sensations (e.g., touch, proprioception, hunger, thirst, libido). There may also be a diminished sense of agency (e.g., feeling robotic, like an automaton; lacking control of one’s speech or movements).

Episodes of derealization are characterized by a feeling of unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings. The individual may feel as if he or she were in a fog, dream, or bubble, or as if there were a veil or a glass wall between the individual and world around. Surroundings may be experienced as artificial, colorless, or lifeless. Derealization is commonly accompanied by subjective visual distortions, such as blurriness, heightened acuity, widened or narrowed visual field, two-dimensionality or flatness, exaggerated three-dimensionality, or altered distance or size of objects, termed macropsia or micropsia.


Depersonalization/derealization disorder is an altered state of self-awareness and identity that results in a feeling of dissociation, or separation, from oneself, one’s surroundings, or both. Because it is normal to feel this way briefly and occasionally—due to side effects of medication, recreational drugs, or some other physical or mental health condition—depersonalization/derealization disorder is usually diagnosed only if such feelings of detachment frequently recur, cause anguish, and interfere with your quality of life.


Depersonalization is a sense of experiencing your own behavior, thoughts, and feelings from a dreamlike distance. You may feel emotionally numb, or as if you are not controlling your own words and actions. Derealization is a sense of distance from activities going on in the world outside of yourself. The world may even seem distorted and somewhat unrecognizable, as if objects are the wrong size or color, time is speeding up or slowing down, or sounds are louder or softer than expected.

The feeling of disconnection associated with depersonalization/derealization disorder is more akin to watching events and activities unfold in a movie or on a computer screen, rather than actually participating in what is going on around you. Episodes may last for hours or days at a time and recur for weeks, months, or even years. At all times, you are aware of both your inner thoughts and what is going on around you, so you are conscious of the fact that you feel detached from yourself and your surroundings.


A history of severe stress, neglect, or physical or emotional abuse can lead to depersonalizaton/derealization disorder. Any of these conditions can also trigger symptoms. Studies have shown that poor sleep quality is associated with more severe symptoms of dissociation.


Since depersonalizaton/derealization disorder often occurs with (and can be triggered by) other mental health problems, such as anxiety and depression, treatment can be difficult. For treatment to be successful, the therapist must develop an individual plan and ultimately address all symptoms and conditions. In addition to psychotherapy, antidepressant and anti-anxiety medications are often used to treat depersonalization/derealization disorder. Research indicates a need for more alternative treatments that are based on the case studies and experiences of clinicians who specialize in dissociative disorders.

Depersonalization/derealization disorder involves a persistent or recurring feeling of being detached from one’s body or mental processes, like an outside observer of their life (depersonalization), and/or a feeling of being detached from one’s surroundings (derealization).

  • The disorder is usually triggered by severe stress, particularly emotional abuse or neglect during childhood, or other major stresses (such as experiencing or witnessing physical abuse).
  • Feelings of detachment from self or the surroundings may occur periodically or continuously.
  • After tests are done to rule out other possible causes, doctors diagnose the disorder based on symptoms.
  • Psychotherapy, especially cognitive-behavioral therapy, is often helpful.

Temporary feelings of depersonalization and/or derealization are common. About one half of people have felt detached from themselves (depersonalization) or from the surroundings (derealization) at one time or another. This feeling often occurs after people

  • Experience life-threatening danger
  • Take certain drugs (such as marijuana, hallucinogens, ketamine, or Ecstasy)
  • Become very tired
  • Are deprived of sleep or sensory stimulation (as may occur when they are in an intensive care unit)

Depersonalization or derealization can also occur as a symptom in many other mental disorders, as well as in physical disorders, such as seizure disorders.


Depersonalization/derealization feelings are considered a disorder when the following occur:

  • Depersonalization or derealization occurs on its own (that is, it is not caused by drugs or another mental disorder), and it persists or recurs.
  • The symptoms are very distressing to the person or make it difficult for the person to function at home or at work.

Depersonalization/derealization disorder occurs in about 2% of the population and affects men and women equally.


The disorder may begin during early or middle childhood. It rarely begins after age 40.


Depersonalization/derealization disorder often develops in people who have experienced severe stress, including the following:

  • Being emotional abused or neglected during childhood
  • Being physically abused
  • Witnessing domestic violence
  • Having had a severely impaired or mentally ill parent
  • Having had a loved one die unexpectedly

Symptoms can be triggered by severe stress (for example, due to relationships, finances, or work), depression, anxiety, or use of illegal or recreational drugs. However, in 25 to 50% of cases, stresses are relatively minor or cannot be identified.


Symptoms of depersonalization/derealization disorder may start gradually or suddenly. Episodes may last for only hours or days or for weeks, months, or years. Episodes may involve depersonalization, derealization, or both.

The intensity of symptoms often waxes and wanes. But when the disorder is severe, symptoms may be present and remain at the same intensity for years or even decades.

Depersonalization symptoms involve

  • Feeling detached from one’s body, mind, feelings, and/or sensations

People may also say they feel unreal or like an automaton, with no control over what they do or say. They may feel emotionally or physically numb. Such people may describe themselves as an outside observer of their own life or the “walking dead.”

Derealization symptoms involve

  • Feeling detached from the surroundings (people, objects, or everything), which seem unreal

People may feel as if they are in a dream or a fog or as if a glass wall or veil separates them from their surroundings. The world seems lifeless, colorless, or artificial. The world may appear distorted to them. For example, objects may appear blurry or unusually clear, or they may seem flat or smaller or larger than they are. Sounds may seem louder or softer than they are. Time may seem to be going too slow or too fast.

The symptoms almost always cause great discomfort. Some people find them intolerable. Anxiety and depression are common. Many people are afraid that the symptoms result from irreversible brain damage. Many worry about whether they really exist or repeatedly check to determine whether their perceptions are real.

Stress, worsening depression or anxiety, new or overstimulating surroundings, and lack of sleep can make symptoms worse.