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Schizophrenia

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Overview

Schizophrenia takes its roots from the Greek word, where schizein means ‘to split’ and phren means ‘mind’. Schizophrenia was previously known as multiple personality disorder or split personality disorder. It is a mental illness, which is characterized by impairments in the perception or expression of reality. It appears most commonly as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, leading to social or occupational dysfunction. Symptoms can be observed in young adulthood.1 Patients can be diagnosed based on self-reported experiences and observed behavior. Laboratory test for schizophrenia does not exist. Genetics, environment during early life, neurobiology, and psychological and social processes are important factors, which contribute to this condition.

This disorder primarily affects the psychological behavior. The patient with this disorder experiences lowering of mood, loss of interest in usual activities, diminished ability to experience pleasure and anxiety disorders. Social problems, such as long-term unemployment, poverty and lack of shelter are common causes this disorder. The life expectancy of the affected individual is decreased by 10–12 years due to various reasons with high suicide rate.2 Approximately, 10% of individuals with schizophrenia commit suicide, and 20–40% make at least one suicide attempt.3

Epidemiology

Schizophrenia affects both males and females with the peak ages of onset being 20–28 years for males and 26–32 years for females. Studies show that schizophrenia can affect all ages (childhood, middle age and old age). Schizophrenia is known to be a major cause of disability.1

Signs and Symptoms

Symptoms of schizophrenia include disorganized thinking, auditory hallucinations and delusions. The affected individuals show signs of catatonia, a syndrome of psychic and motor disturbances. A schizophrenia-like psychosis of shorter duration is termed a schizophreniform disorder.

Isolation from social gathering is a common factor and occurs due to various reasons. Many people diagnosed with schizophrenia avoid stressful social situations that may increase their mental distress.4

Late adolescence and early adulthood are critical periods for the onset of schizophrenia. Much work has been recently carried out to identify and treat the preonset of the illness.5

Preonset symptoms like social isolation, irritability, depressed mood and transient or self-limiting psychosis are experienced before psychosis becomes apparent in their later life.6

Schizophrenia is described in terms of negative and positive symptoms. The positive (or productive) symptoms include the following:

  • Delusions:  False belief.
  • Auditory hallucinations:  False perception of sound.
  • Thought disorder:  Irregularities in speech reflecting disorganized thinking.

The negative (or deficit) symptoms include the following:

  • Blunted affect and emotion: Lack of emotional reactivity.
  • Poverty of speech: Termed as alogia or lack of speech
  • Anhedonia: Inability to experience pleasure.
  • Lack of motivation: Termed avolition or lack of desire to pursue to meaningful goals.

Diagnosis

Diagnosis is based on the person’s own experiences, observed behavioral changes reported by family members, friends or coworkers, and secondary signs observed by a psychiatrist, a social worker or a clinical psychologist help in diagnosing schizophrenia. There are no biological tests to confirm schizophrenia; tests are carried out to exclude medical illnesses. These include blood tests measuring thyrotropin-stimulating hormone (TSH) to exclude hypo- or hyperthyroidism, full blood count including erythrocyte sedimentation rate (ESR) to rule out a systemic infection or chronic disease, serology to exclude syphilis or HIV infection. Two commonly ordered investigations are electroencephalogram (EEG) to exclude epilepsy and a computerized tomography (CT) scan of the head to exclude brain lesions. Delirium, which can be observed by visual hallucinations and fluctuating level of consciousness are important factors to detect this illness.

To be diagnosed with schizophrenia, a person must display the following characteristic symptoms:

  • Delusions
  • Hallucinations
  • Disorganized speech (e.g., frequent derailment or incoherence; speaking in abstracts).
  • Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently) or catatonic behavior
  • Negative symptoms, that is, affective flattening (lack or decline in emotional response), alogia (lack or decline in speech), or avolition (lack or decline in motivation).

Causes

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Environmental factors or stressors influence onset of schizophrenia. Discussed below are some of these factors.

Genetic

Schizophrenia is a condition of complex inheritance, where several genes interact to produce this condition. Genes responsible for developing schizophrenia are not specific and there is always a possibility of developing other psychotic disorders such as bipolar disorder (presence of one or more episodes of abnormally elevated mood).

Prenatal

Exposing to infections at early neurodevelopmental phase, including during pregnancy increase the risk of developing schizophrenia in the later ages.7

Substance Abuse

People suffering with schizophrenia use certain drugs to overcome negative feelings associated with it. Drugs like amphetamines bring about the release of dopamine and excessive dopamine function is believed to raise risk for schizophrenia (known as the dopamine hypothesis of schizophrenia).8 Hallucinogenic or stimulant drugs also triggers onset of schizophrenia when used in excess.

Psychological

Studies show that a number of factors like stress, confusing situations (attention to potential threats, jumping to conclusions, making external attributions, impaired reasoning about social situations and mental states), difficulties with early visual processing and maintaining concentration are psychological causes for this condition. The patients are highly responsive to stress or negative stimuli.

Childhood experiences of abuse or trauma and social disadvantages like poverty and migration, racial discrimination, family dysfunction, unemployment or poor housing conditions have found to be risk factors. There is also an increased risk when there are breakups in parental relationships.

Neural

Evidence shows that finding the drug group phenothiazines, helped in blocking the dopamine function thereby reducing the psychotic symptoms. An influential theory known as the dopamine hypothesis of schizophrenia, proposes that malfunction involving dopamine pathways was the cause of (the positive symptoms of) schizophrenia.

Studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia. Many of these differences are detected when comparing groups of people. Brain structure changes have also been found out in patients suffering from schizophrenia after administration of antipsychotic drugs.

Treatment

Treatment in schizophrenia involves taking the correct medicines with minimum side-effects and personal support. Consulting a doctor should not be delayed. In schizophrenia, it is very important to start with the treatment early to lead a normal life. Treatment involves assessments using standardized method like positive and negative syndrome scale (PANSS). This is a medical scale used for measuring the severity of symptoms in this condition.

Present medication available does not cure this condition but helps in restoring normal functioning of the brain. Long-lasting medication ensures continuous relief psychotic symptoms.

Patients undergoing treatment for this condition usually do not continue the medications prescribed. After the first year of treatment, most patients will discontinue their use of medications, especially the ones where the side-effects are difficult to tolerate.

Patients suffering with severe episodes of schizophrenia need to be hospitalized. This can be voluntary or involuntary. Long-term hospitalization is now decreased due to the practice of moving people from mental institutions into family-based environments.9 Hospitalization might be necessary in severe conditions. Hence, treating schizophrenia depends on:

  • Psychopharmacologic treatment (medications)
  • Psychotherapeutic treatment (psychosocial therapy, individual or group): Individual or group treatment involves meeting frequently and lectures from guest speakers to educate them about caring, sharing, mutual support, which is important in the recovery process. Psychosocial therapy involves frequent talks with the physician, psychologist or social worker. The sessions involve discussions and sharing about past problems, experiences, thoughts and feelings. This support helps them to overcome the difficult aspects of this condition.
  • Rehabilitation support (social, living skills and family education): Rehabilitation program is very important for the patients to lead a normal life outside the hospital. These programs focuses on improving job skills use of public transport, money management skills, and problem solving skills. Family therapy is a form of treatment, which involves addressing the whole family members about the advantages and disadvantages of schizophrenia.  Caregivers are thought various coping strategies and problem solving skills. This has been found to be beneficial if the duration of intervention is for a longer term.

Apart from this therapy, the impact of schizophrenia on families and the burden on carers has been recognized with the guidance available through of self-help books.

Medications

Antipsychotic medications are used to treat schizophrenia. These medications take around 7–14 days to show their effect and decrease the positive symptoms. Following are some of the antipsychotic drugs used in treating schizophrenia

Trifluoperazine: Is used for short-term treatment of anxiety. It helps in stabilizing the symptoms of schizophrenia by improving their mood and making them easier to function in everyday life.

Haloperidol: This medicine helps to think more clearly, feel less nervous, take part in everyday life, and prevent committing suicide. It also reduces aggression and the desire to hurt others.

Ziprasidone: Is used when other medications are not effective and works by maintaining the balance of certain natural chemicals called neurotransmitters in the brain.

Clozapine, Quetiapine, Thiothixene and Olanzapine: These medications work by helping to maintain the balance of neurotransmitters in the brain.

Risperidone: Is a common antipsychotic medication. It also helps to think clearly and makes functioning of daily activities easy. It can decrease negative thoughts and hallucinations.

Response to these medications is varies. The term ‘treatment-resistant schizophrenia’ is used for patients failing to respond satisfactorily to at least two different antipsychotic medications. Patients coming under this category are prescribed with medication of superior effectiveness. Such medication has potentially high lethal side-effects.

Patients who are unwilling or unable to take medications regularly, high-potency antipsychotic medication may be given every 2 weeks to achieve control. Long-term usage of such high-potency antipsychotics is not advised.

Over-the-counter drug (OTC): Haloperidol is the commonly available OTC drug.

Alternative therpy: This therapy is advised after consulting with a physician. The following are some of them coming under this category.

  • Glycine supplements: Glycine is an amino acid, which helps in reducing the negative symptoms of schizophrenia.
  • Omega-3 fatty acids: Helps in reducing the negative and positive symptoms of schizophrenia.
  • Antioxidants: Antioxidants like vitamin E, vitamin C and alpha-lipoic acid show mild improvement to this condition.
  • Electroconvulsive therapy (ECT): Can be considered and may be prescribed in cases where other treatments have failed.
  • Transcranial magnetic stimulation (TMS): This is and alternative to ECT. This treatment is considered as the last resort for people with severe depression.

References

1.Castle E, Wessely S, Der G, Murray RM. "The incidence of operationally defined schizophrenia in Camberwell 1965-84". British Journal of Psychiatry 1991; 159: 790–794.

2.Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry. 2000; 177: 212–217.

3.Available at: www.mentalhealth.com/dis/p20-ps01.html. Accessed on 18th Mar, 2008.

4.Freeman D, Garety PA, Kuipers E, et al. "Acting on persecutory delusions: the importance of safety seeking". Behavior Research and Therapy. 2007; 45 (1): 89–99.

5.Addington J, Cadenhead KS, Cannon TD, et al. "North American prodrome longitudinal study: a collaborative multisite approach to prodromal schizophrenia research". Schizophrenia Bulletin. 2007; 33 (3): 665–672.

6.Parnas J, Jorgensen A. "Pre-morbid psychopathology in schizophrenia spectrum". British Journal of Psychiatry. 1989; 115: 623–627.

7.Brown AS. "Prenatal infection as a risk factor for schizophrenia". Schizophrenia Bulletin. 2006; 32 (2): 200–202.

8.Laruelle M, Abi-Dargham A, van Dyck CH, et al. "Single photon emission computerized tomography imaging of amphetamine-induced dopamine release in drug-free schizophrenic subjects". Proceedings of the National Academy of Sciences of the USA.1996; 93: 9235–9240.

9.Becker T, Kilian R. "Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care". Acta Psychiatrica Scandinavica Supplement. 2006; 429: 9–16.

Written by: Saptakee sengupta
Date last updated: April 18, 2015