Schizophrenia is a complex and often misunderstood mental health condition that affects approximately 1% of the global population, with significant variations in symptom presentation and cultural challenges (NIMH). In India, where stigma and limited mental health infrastructure persist, families play a pivotal role in supporting recovery. This article explores the clinical nuances of schizophrenia, evidence-based treatments, and culturally sensitive strategies for caregivers in India.
Understanding Psychosis Vs Schizophrenia:
Psychosis and schizophrenia are often confused, but they are distinct concepts. Psychosis refers to a set of symptoms like hallucinations (hearing voices) and delusions (false beliefs) that impair a person’s connection with reality. It can occur in various conditions, such as bipolar disorder, severe depression, or substance use.
Schizophrenia however is a chronic mental health disorder that is marked by the presence of psychotic symptoms like delusions, hallucinations, and/or disorganised behaviour and thought patterns along with social withdrawal and socio-occupational dysfunction. It is better to think of psychosis as the symptoms, and Schizophrenia as the illness. (Sadock, 2015)
Clinical Types of Schizophrenia (Ahuja, 2011)
People with this type often feel extremely suspicious or fearful. They might believe others are plotting against them (delusions) or hear voices that aren’t there (hallucinations). Despite this, their thinking and daily functioning may seem relatively normal compared to other types.
This type involves jumbled speech, unpredictable behavior (like laughing at a sad moment), and difficulty showing appropriate emotions. It usually starts in the teenage years and can make school, work, or relationships very challenging.
Individuals may “freeze” physically—staying silent, motionless, or stuck in odd postures for hours. Sometimes, they might suddenly become hyperactive or repeat others’ words. These extreme changes in movement are hallmarks of this type.
After the worst symptoms (like hallucinations) fade, people may still struggle with low motivation, social withdrawal, or flattened emotions. It’s like the “aftermath” of an acute episode.
This is a mix of symptoms that don’t fit neatly into other categories. For example, someone might have both hallucinations and disorganized behavior but not clearly match one specific type.
This type develops slowly over time, with a gradual loss of interest in life, reduced speech, and neglect of self-care. Unlike other types, there are no obvious hallucinations or delusions—just a steady decline in daily functioning.
After recovering from severe psychotic symptoms, some people experience a period of deep sadness, hopelessness, or guilt. This depression can increase the risk of relapse or self-harm.
This category includes rare or unusual forms of schizophrenia, such as cases that start in childhood or symptoms that don’t match the typical patterns.
Etiology/Causes of Schizophrenia
Schizophrenia may arise from a mix of factors (NIMH):
Environmental triggers: Childhood trauma, urban upbringing, or substance use (e.g., cannabis) can heighten risk of developing symptoms.
While caregivers can’t control genetics or past traumas, they can focus on creating a stable home environment and reducing stressors. These insights highlight the need for early intervention, particularly in adolescents showing signs like social withdrawal or declining academic performance (Sadock, 2013).
Symptoms and Diagnosis:
Schizophrenia manifests through a triad of symptoms:
positive (hallucinations, delusions)
negative (social withdrawal, anhedonia)
cognitive (impaired memory, executive dysfunction).
Diagnosis requires at least two symptoms persisting for six months for the DSM-5, and one month or more in the ‘active phase’ for ICD-10, with significant functional impairment (APA, 2013; WHO, 2016).
Why Diagnosis is Often Delayed in India:
Treatment Approaches:
Effective management combines pharmacotherapy, psychosocial interventions, and community support.
Second-generation antipsychotics target dopamine and serotonin receptors, mitigating positive symptoms with fewer side effects than first-generation drugs (Masika, 2025).
Psychosocial interventions, such as cognitive-behavioral therapy (CBT) and family psychoeducation, are critical for addressing negative symptoms and improving social functioning.
Emerging therapies, including digital mental health platforms, offer promise in resource-limited settings. Tele Counselling services in cities like Mumbai and Delhi bridge gaps in access, while community-based rehabilitation programs integrate vocational training and peer support (Seshadri et al., 2019).
Electroconvulsive therapy (ECT) is reserved for severe, treatment-resistant cases, though its use remains controversial (Masika, 2025).
Medication Compliance Challenges:
Patient Factors: Their lack of insight i.e. their belief that they are not sick, leads to their refusal to comply with the prescribed treatment and medications.
Caregivers Factors: Various myths about the psychiatric medications causing addiction or ‘brain damage’ leads to reluctance to comply with the treatment plan or early termination of medications without consulting with the doctor.
What Caregivers can Control V/S What They Cannot:
Can Control | Cannot Control |
Medication Compliance | Genetic Predisposition |
Home environment | Past traumas |
Social Support Network | Societal Stigma |
Strategies for Caregivers:
Supporting a loved one with schizophrenia requires empathy, patience, and cultural competence.
Education is vital:
Having a deep understanding of the patient’s condition and their lack of insight helps families respond compassionately during psychotic episodes.
Caregivers should collaborate with clinicians to understand the importance of medication compliance, and start using journals to track symptoms and triggers that worsen symptoms.
Creating a Supportive Home Environment:
Avoid High Expressed Emotions (EE): Criticism, hostility, or over-involvement increases the risk for relapse. Instead, use calm and affirming language to promote self-confidence in the patient.
Reduce Sensory Overload: Use dim lights in the room, avoid crowded spaces, and maintain quiet during psychotic episodes.
Educating Others:
Explain the diagnosis to teachers, employers, or relatives to reduce stigma. Example: “He needs patience, not judgment”
Crisis Management:
Look for warning signs: Agitation, refusing medication, or talking to unseen people.
During a crisis state, try to stay calm, avoid arguing with the patient, and use reassuring phrases, such as, “You are safe here, we do not want to hurt you.”
Plan Ahead: Keep emergency contacts (psychiatrists, hospital emergency services) handy.
Boundaries and Self-Care:
Set Limits: It’s okay to sometimes say, “I need 30 minutes for myself to recharge.”
Join Support Groups: Connect with others facing similar challenges via social media or the VIMHANS Self-Help Group.
Burnout is prevalent, with 60% of Indian caregivers reporting chronic stress. Mindfulness practices like meditation may mitigate this burden (Seshadri et al., 2019).
Conclusion:
Schizophrenia demands compassion, education, and teamwork. By focusing on actionable strategies—like monitoring symptoms, fostering calm, and setting boundaries—caregivers can empower recovery while safeguarding their own well-being.
--- By Syed Hammad Ali
References:
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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing
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Loganathan, S., & Murthy, R. S. (2011). Gender-based stigma in schizophrenia: A socio-cultural perspective. Transcultural Psychiatry, 48(5), 569–584 https://doi.org/10.1177/1363461511418872
Masika, A. K. (2025). A Conceptual Approach to Integrating Multidimensional Theories in Psychological Interventions for Schizophrenia. ShahidiHub International Journal of Education, Humanities & Social Science, 3(1), 18-33
National Institute of Mental Health. (n.d.). Schizophrenia.
https://www.nimh.nih.gov/health/statistics/schizophrenia
Sadock, B. J. (2015). Kaplan & Sadock's synopsis of psychiatry: behavioral sciences/clinical psychiatry (Vol. 2015, pp. 648-655). Philadelphia, PA: Wolters Kluwer.
Seshadri, K., Sivakumar, T., & Jagannathan, A. (2019). The family support movement and schizophrenia in India. Current Psychiatry Reports.
World Health Organization. (1973). Report of the International Pilot Study of Schizophrenia. World Health Organization.
World Health Organization. (2016). International statistical classification of diseases and related health problems (10th ed.). https://icd.who.int/