Schizophrenia

What is Schizophrenia ?

It is a brain disorder that affects the way a person acts, thinks, and sees the world.  People with schizophrenia have an altered perception of reality, often a significant loss of contact with reality.  They may see or hear things that do not exist, speak in strange or confusing ways, believe that others are trying to harm them, or feel like they’re being constantly watched. With such a blurred line between the real and the imaginary, schizophrenia makes it difficult—even frightening—to negotiate the activities of daily life. In response, people with schizophrenia may withdraw from the outside world or act out in confusion and fear.

Facts

• Schizophrenia affects about 24 million people worldwide.
• 90% of people with untreated schizophrenia are in developing countries
• Schizophrenia is a treatable disorder, treatment being more effective in its initial stages
• Schizophrenia affects men and women equally
• It occurs at similar rates in all ethnic groups around the world
• Most cases of schizophrenia appear in the late teens or early adulthood
• For men, the average age of onset is 25. For women, typical onset is around the age of 30. However, schizophrenia can appear for the first time in middle age or even later
• In rare cases, schizophrenia can even affect young children and adolescents
• The earlier schizophrenia develops, the more severe it is
• It is also difficult to diagnose schizophrenia in teens, because the first signs include a change of friends, a drop in grades, sleep problems, and irritability that are common behaviours among teens
• Schizophrenia also tends to be more severe in men than in women. More than 50 % of persons with schizophrenia are not receiving appropriate care
• Care of persons with schizophrenia can be provided at community level, with active family and community involvement
• The earlier the treatment is initiated, the more effective it will be. However, the majority of the persons with chronic schizophrenia do not receive treatment, which contributes to the chronicity

Although schizophrenia is a chronic disorder, there is help available. With support, medication, and therapy, many people with schizophrenia are able to function independently and live satisfying lives. However, the outlook is best when schizophrenia is diagnosed and treated right away. If you spot the signs and symptoms of schizophrenia and seek help without delay, you or your loved one can take advantage of the many treatments available and improve the chances of recovery.  But in most cases, it starts slowly, with subtle warning signs and a gradually decline in functioning before the first severe episode.

Most common early warning signs of schizophrenia include:

• Social withdrawal
• Hostility or suspiciousness
• Deterioration of personal hygiene
• Flat, expressionless gaze
• Inappropriate laughter or crying
• Depression
• Odd or irrational statements
• Strange use of words or way of speaking
• Sleep disturbances
• Talking to self /smiling to self

Note:these warning signs can result from a number of problems—not only in schizophrenia— but they are cause for concern. The ordinary behaviour is causing problems in your life or the life of a loved one, seek medical advice. If schizophrenia or any another mental problem , treatment will help.

Causes of Schizophrenia

The causes of schizophrenia are not fully known.  However, it appears that schizophrenia usually results from a complex interaction between genetic and environmental factors.

Genetic causes

Schizophrenia has a strong hereditary component. Individuals with a first-degree relative (parent or sibling) who has schizophrenia have a 10 percent chance of developing the disorder, where as as to the 1 percent chance of the general population. But schizophrenia is only influenced by genetics, not determined by it.  While schizophrenia runs in families, about 60% of schizophrenics have no family members with the disorder.  Furthermore, individuals who are genetically predisposed to schizophrenia don’t always develop the disease, which shows that biology is not destiny.

Environmental causes

Twin and adoption studies suggest that inherited genes make a person vulnerable to schizophrenia and then environmental factors act on this vulnerability to trigger the disorder. High levels of stress are believed to trigger schizophrenia by increasing the body’s production of the hormone cortisol. Research points to several stress-inducing environmental factors that may be involved in schizophrenia, including:

• Prenatal exposure to a viral infection
• Low oxygen levels during birth (from prolonged labour or premature birth)
• Exposure to a virus during infancy
• Early parental loss or separation
• Physical or sexual abuse in childhood

Abnormal Brain Structure

Abnormal brain chemistry, like dopamine imbalance and abnormalities in brain structure may also play a role in schizophrenia. There is evidence of enlarged brain ventricles and abnormally low activity in the frontal lobe, the area of the brain responsible for planning, reasoning, and decision-making.

Some studies also suggest that abnormalities in the temporal lobes, hippocampus, and amygdale are connected to schizophrenia’s positive symptoms. But despite the evidence of brain abnormalities, it is highly unlikely that schizophrenia is the result of any one problem in any one region of the brain.

Symptoms of Schizophrenia

There are five types of symptoms characteristic of schizophrenia: delusions, hallucinations, disorganized speech, disorganized behaviour, and the so-called “negative” symptoms. These also lead to cognitive symptoms that interfere with daily activities. However, the signs and symptoms of schizophrenia vary dramatically from person to person, both in pattern and severity.

Delusions

A delusion is a firmly-held belief that a person has despite clear and obvious evidence that it is not true. Delusions are extremely common in schizophrenia, occurring in more than 90% of those who have the disorder. Often, these delusions involve illogical or bizarre ideas or fantasies. Common schizophrenic delusions include:

• Delusions of persecution: Belief that others, often a vague “they”, are out to harm him or his family members. These persecutory delusions often involve bizarre ideas and plots.
• Delusions of reference: A neutral environmental event is believed to have a special and personal meaning.  For example, a person with schizophrenia might believe a billboard or a person on TV is sending a message meant specifically for them.
• Delusions of grandeur: Belief that one is a famous or important figure, such as Jesus Christ. Alternately, delusions of grandeur may involve the belief that one has unusual powers that no one else has (e.g. the ability to fly).
• Delusions of control: Belief that one’s thoughts or actions are being controlled by outside, alien forces.

Hallucinations

Hallucinations

• Visual (seeing things that are not there or that other people cannot see)
• Auditory (hearing voices that other people can't hear
• Tactile (feeling things that other people don't feel or something touching your skin that isn't there.)
• Olfactory (smelling things that other people cannot smell, or not smelling the same thing that other people do smell)
• Gustatory experiences (tasting things that isn't there)

Auditory hallucinations (e.g. hearing voices or some other sound) are most common in schizophrenia. Visual hallucinations are also relatively common. Research suggests that auditory hallucinations occur when people misinterpret their own inner self-talk as coming from an outside source.
Schizophrenic hallucinations are usually meaningful to the person experiencing them. Many times, the voices are those of someone they know. Most commonly, the voices are critical, vulgar, or abusive. Hallucinations also tend to be worse when the person is alone.

Disorganized Speech

Fragmented thinking is characteristic of schizophrenia. Externally, it can be observed in the way a person speaks. People with schizophrenia tend to have trouble concentrating and maintaining a train of thought. They may respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, speak incoherently, or say illogical things.
Common signs of disorganized speech in schizophrenia include:

• Loose associations:Rapidly shifting from topic to topic, with no connection between one thought and the next.
• Neologisms:Made-up words or phrases that only have meaning to the patient.
• Perseveration: Repetition of words and statements; saying the same thing over and over.

Disorganized Behaviour

Schizophrenia disrupts goal-directed activity, causing impairments in a person’s ability to take care of him or herself, work, and interact with others. Disorganized behavior appears as:

• A decline in overall daily functioning
• Unpredictable or inappropriate emotional responses
• Behaviors that appear bizarre and have no purpose
• Lack of inhibition and impulse control

Negative Symptoms

The so-called “negative” symptoms of schizophrenia refer to the absence of normal behaviors found in healthy individuals. Common negative symptoms of schizophrenia include:

• Lack of emotion - the inability to enjoy regular activities (visiting with friends, etc.) as much as before
• Low energy - the person tends to sit around and sleep much more than normal
• Lack of interest in life, low motivation
• Lack of inhibition and impulse control
• Affective flattening - a blank, blunted facial expression or less lively facial movements, flat voice (lack of normal intonations and variance) or physical movements.
• Alogia - difficulty or inability to speak
• Inappropriate social skills or lack of interest or ability to socialize with other people
• Inability to make friends or keep friends, or not caring to have friends
• Social isolation - person spends most of the day alone or only with close family

Cognitive Symptoms of Schizophrenia

Cognitive symptoms refer to the difficulties with concentration and memory. These can include:

• Disorganized thinking
• Slow thinking
• Difficulty understanding
• Poor concentration
• Poor memory
• Difficulty expressing thoughts
• Difficulty integrating thoughts, feelings and behaviour

Schizophrenia Diagnosis

There is currently no physical or lab test that can absolutely diagnose schizophrenia - a psychiatrist usually comes to the diagnosis based on clinical symptoms. Many conditions may have similar symptoms and physical testing can rule out a lot of other conditions like seizure disorders, metabolic disorders, thyroid dysfunction, brain tumor, street drug use, drugs, head injury. To diagnose schizophrenia the symptoms must present persistently for longer period and should interfere with his daily activities, occupational functioning and interfere with social and interpersonal relations.

Different types of Schizophrenia

There are five types of schizophrenia, each based on the kind of symptoms the person has at the time of assessment.

• Paranoid schizophrenia: The individual is preoccupied with one or more delusions or many auditory hallucinations but does not have symptoms of disorganized schizophrenia.
• Disorganized schizophrenia: Prominent symptoms are disorganized speech and behavior, as well as flat or inappropriate affect.
• Catatonic schizophrenia: The person with this type of schizophrenia primarily has at least two of the following symptoms: difficulty moving, resistance to moving, excessive movement, abnormal movements, and/or repeating what others say or do.
• Undifferentiated schizophrenia: This is characterized by episodes of two or more of the following symptoms: delusions, hallucinations, disorganized speech or behaviour, catatonic behaviour or negative symptoms, but the individual does not qualify for a diagnosis of paranoid, disorganized, or catatonic type of schizophrenia.
• Residual schizophrenia: While the full-blown characteristic positive symptoms of schizophrenia (those that involve an excess of normal behaviour, such as delusions, paranoia, or heightened sensitivity) are absent, the sufferer has a less severe form of the disorder or has only negative symptoms (symptoms characterized by a decrease in function, such as withdrawal, disinterest, and not speaking).

Effects of Schizophrenia

When the signs and symptoms of schizophrenia are ignored or improperly treated, the effects can be devastating both to the individual with the disorder and those around him or her. Some of the possible effects of schizophrenia are:

• Relationship problems: Relationships suffer because people with schizophrenia often withdraw and isolate themselves. Paranoia can also cause a person with schizophrenia to be suspicious of friends and family.
• Disruption to normal daily activities: Schizophrenia causes significant disruptions to daily functioning, both because of social difficulties and because everyday tasks become hard, if not impossible to do. A schizophrenic person’s delusions, hallucinations, and disorganized thoughts typically prevent him or her from doing normal things like bathing, eating, or running errands.
• Difficulty in occupational functioning: Due to disturbed relationships and difficulty in normal daily activities people with schizophrenia cannot perform their job responsibilities.
• Alcohol and drug abuse: People with schizophrenia frequently develop problems with alcohol or drugs, which are often used in an attempt to self-medicate, or relieve symptoms. In addition, they may also be heavy smokers, a complicating situation as cigarette smoke can interfere with the effectiveness of medications prescribed for the disorder.
• Increased suicide risk: People with schizophrenia have a high risk of attempting suicide. Any suicidal talk, threats, or gestures should be taken very seriously. People with schizophrenia are especially likely to commit suicide during psychotic episodes, during periods of depression. About 10% die by suicide.
• Schizophrenia and violence: People with schizophrenia are not usually violent. In fact, most violent crimes are not committed by people with schizophrenia. However, some symptoms are associated with violence, such as delusions of persecution. Substance abuse may also increase the chance a person will become violent. If a person with schizophrenia becomes violent, the violence is usually directed at family members and tends to take place at home.

Treatment

Treatment options for schizophrenia are good, and the outlook for the disorder continues to improve. With medication, psycho therapy, and a strong support network, many people with schizophrenia are able to control their symptoms, gain greater independence, and lead fulfilling lives. 
Management depends largely on medications and on psychosocial interventions.
Hospitalization may be required in only severe episodes of schizophrenia. The mainstay of psychiatric treatment for schizophrenia is antipsychotic medication. Patients who are unwilling or unable to take medication regularly, long-acting depot preparations (injectables) of antipsychotics may be given every two weeks to achieve control. Electroconvulsive therapy is not considered a first line treatment but may be prescribed in cases where other treatments are ineffective.

Tips for Better Management

• If early signs of schizophrenia are detected consult psychiatrist immediately
• Communicate with doctor openly and discuss freely about symptoms, medication and side effects.
• Fallow the instruction correctly regarding dosage, duration of treatment. Never reduce or stop medications.
• Build a support system with trusted friends and family members.
• Manage stress effectively by knowing your limits as stress can trigger psychosis.
• Maintain adequate exercise nutritious diet and sleep.
• Avoid alcohol and other illicit drugs.
• Work towards life goals.
• Family members must help patient in taking regular medication and follow other instructions and report to concerned doctor immediately if necessary.

Encouraging facts about schizophrenia

• Schizophrenia is treatable. Currently there is no cure for schizophrenia, but the illness can be successfully treated and managed. The key is to have a strong support system in place and get the right treatment for your needs.
• You can enjoy a fulfilling, meaningful life. When treated properly, most people with schizophrenia are able to have satisfying relationships, work or pursue other meaningful activities, be part of the community, and enjoy life.
• Just because you have schizophrenia doesn’t mean you’ll have to be hospitalized. If you’re getting the right treatment and sticking to it, you are much less likely to experience a crisis situation that requires hospitalization to keep you safe.
• Most people with schizophrenia get better over time, not worse. People with schizophrenia can regain normal functioning and even become symptom free. No matter what challenges you presently face, there is always hope.

Source: Dr. Sudha Rani, Assistant Professor of Psychiatry, Institute of Mental Health, Hyderabad