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Schizophrenia; Overview of Schizophrenia Disorder

Schizophrenia is a mental disorder that is characterized by a disturbance in reality testing. Sometimes, these patients are not able to differentiate what is real or not. The common symptoms are firm beliefs such as someone trying to spy on him. He may hear voices or see things. In addition, an oddity of behavior is also common. Schizophrenia is unduly attributed to aggression and dangerousness. That is not the case. For details see “myths about schizophrenia”.

This illness is long-standing and will persist for years. It not treated properly, further complications will arise such as aggression or decreased self-care. Another complication of delay in treatment is the marked decline of cognitive functions.

Recent studies strongly suggest to diagnose it early and start treatment as soon as possible. The main benefit of treatment is a good recovery from illness.

Five core symptoms of schizophrenia

  1. Problems of thoughts/ Delusions

A patient develops a firm belief. Sometimes, this is understandable and sometimes not. Few examples for given below. 

Example 1; Paranoid delusions

A patient starts believing that other persons are against him, they are trying to kill him, they follow him through hidden cameras, they poison his food, etc. but actually there are no such threats. As a result, the patient becomes fearful and usually refuses to take food because of the fear that someone poisoned it, sometimes patient start keeping weapons as self-defense against the assumed threat.

Example 2; delusions of control

A patient starts believing that some other person or party is controlling him. They can control his thoughts actions and feelings.

  1. Problems of perception/ Hallucinations

This means hearing voices and seeing an object in absence.
For example, the patient hears voices that command him to certain things we call this Commanding Hallucinations. Other content of voices can be insulting, threatening, giving comments on patients’ actions.
Similarly patient can see the objects or persons in absence.

Remember, these hallucinations are vivid, delineated and as clear as a real image. Sometimes, we observe that the patient is talking to himself (self-talking), but actually, he may be talking to the voices that are only heard by him

  1. Behavioral problems

The oddity of behavior includes talking to him-self, smiling to himself, making bizarre gestures and movements, wearing clothes that are not appropriate to the weather. These problems also vary from patient to patient. Some can be abusive and violent, others isolate them totally.

All these symptoms result in a marked decline in functioning, at work, at school or at home

  1. Irrelevant Talk:

You will observe that schizophrenia patients are talking irrelevantly. In this case, they lack the ability to stay on topic. Sometimes they jump from one topic to another without having any connection in them. We call this “loosening of association.” Sometimes they tell undue details of a single topic, we call this “circumstantiality.”

  1. Negative symptoms:

These include social isolation, decreased communication, and apathy, blunt and emotionless expressions.

What can cause schizophrenia? / Who are at more risk to develop schizophrenia

There are multiple factors. And they can have a cumulative effect. Usually, a single factor can’t cause schizophrenia.

  1. Genetics

    :

Studies have proven that genetics play a key role in the development of schizophrenia. A lot of genes are identified that can be associated with this disorder. The risk of developing schizophrenia increases by 10% in 1st-degree relatives. For monozygotic twins, this is 50%

  1. Brain changes:

Some brain areas are found to be shrunken in patients with schizophrenia such as the hippocampus and prefrontal cortex. Ventricles of the brain are dilated.  And there are certain chemicals whose level is increased in the brain such as dopamine and serotonin. And these two brain changes are the target of drugs used to treat schizophrenia

  1. Birth and early childhood experiences

Chances of developing schizophrenia are increased in those who experienced difficult labor, birth trauma, head injury, child abuse, and child neglect. Surprisingly the maternal influenza infection at mid-trimester increased of risk of developing schizophrenia to 7 fold in the children.
Maternal malnutrition; Children who are born to mothers whose nutrition was deficient during early pregnancy, they were more likely to develop schizophrenia later in life.
Parental age; the risk of development of schizophrenia is also related to the age of parents at birth. As the parental age increases, risk increases. According to one study, the chances of developing schizophrenia increases by 50% by every ten-year increase in parental age.

  1. Family’s causative role in schizophrenia:

Two types of a pathological family patterns have been observed.

Marital skew which means one parent is extremely dominant especially mother and has eccentricities in her behavior and other parent has to adjust to these eccentricities. 

Marital schism; both parents maintained different views and the child has to decide between the loyalties of parents. These abnormalities are found to be a cause of schizophrenia rather than a result of schizophrenia

  1. Life events and other Social Factors:

These factors don’t cause schizophrenia. But if a person is already predisposed to schizophrenia these factors increase the chances of developing it and compromise the long term outcome.  These factors include

  • Childhood abuse and trauma; when schizophrenic patients’ lives were observed retrospectively, it was found that they were victims of emotional, physical or sexual abuse. Some of them experienced major trauma or major medical illness during early childhood.
  • Paternal marital conflicts,
  • High expressed emotions in the family. See Family and schizophrenia
  • Social isolation; patients suffering from schizophrenia often live isolated, they have few friends, usually unmarried. This behavior may be evident even before the development of illness.
  1. Drug abuse and schizophrenia;

Some drugs of abuse are strongly associated with schizophrenia. And this relationship is bilateral. That means drugs increase the risk of schizophrenia and schizophrenia patients themselves are prone to use the addictive drug. Among different drugs of abuse, cannabis is highly associated with the development of schizophrenia. It is worth mentioning that cannabis is considered less addictive as it has minimal physical dependence but its relation with schizophrenia as a causative agent is significantly established.  Similarly, the relationship of alcohol is also established especially paranoid delusions and pathological jealousy.

Three domains of Schizophrenia Treatment

  1. Drug treatment of schizophrenia

The mainstay of acute treatment of schizophrenia is medicine. Psychotherapy is even contraindicated in the acute phase

There are two main classes of drugs for schizophrenia
1. typical antipsychotics
2. atypical antipsychotics

For detail of drug treatment see schizophrenia medicine

Few things need to remember regarding drug treatment for schizophrenia.

  • They are to be continued for a longer period of time. For example in 1st episode treatment is usually continued to 2 years after remission of symptoms
  • These are not addictive medicines
  • Like any other medicine, these are not free from side effects. But not all side effects appear in all patients. 
  • If the patient experiences side effects medicine need not be stopped. Because these side effects are reversible and can be managed with adjustment of medicine. For this purpose, you need to consult your psychiatrist
  1. Psychological treatment / Can psychotherapy be effective in schizophrenia

One of the important components of the psychological treatment of schizophrenia is to help the patient gain insight into the illness. This can be achieved when the patient has started responding to drug treatment. Common psychological interventions are

  1. Cognitive behavior therapy

The use of cognitive behavior therapy is based on the principle that the underlying thought process present in delusions is challenged by structured reasoning. Direct confrontation is avoided as it can provoke aggression. During the acute phase of illness, it is difficult to challenge the delusion. So CBT is usually applied when delusions are not fully formed or the patient is partially treated with medicine. Similarly, this technique can also be used to modify the beliefs regarding the origin of hallucinations

  1. Cognitive remediation

Impairment in cognitive functioning is highly associated with schizophrenia. This can be part of the illness or side effects of antipsychotic medication. In this technique, the patient has to do some mental exercises to enhance their cognitive functions

  1. Role of Family and social treatment in schizophrenia

Family and social circumstances also play a key role. These interventions are usually adjuvant to drug treatment that is still the main treatment option. These include education of family regarding the illness, diagnosis, treatment options, chances of recovery, etc. Sometimes high expressed emotions in the family also deteriorate the prognosis. These include hostility, overprotectiveness, and emotional over-involvement. These behaviors of the family need to be addressed. Similarly, a family can also have a major role to adhere to the patient to a treatment care plan. In some cases, supported employment and work do well in this disorder.

Two important questions

  1. Why it is necessary to take medicine regularly?

In schizophrenia, medicines are to be taken regularly for a longer period of time. Adherence means not only to take medicine regularly but also to follow the other instructions, make regular visits, inform the physician regarding side effects. The importance of adherence is that it increases the long term recovery, improves the functioning of the patient and reduces the chances of relapse. 

But what happens actually, patients usually stop medicines or reduce the dose of medicine. There can be multiple reasons for this. Sometimes patients sop medicine due to their side effects. Sometimes they think that medicine is not needed as they are not ill. Sometimes their health belief models put a hindrance to treatment. For example, they may consider these symptoms as supernatural. There can be different reasons for non-adherence but they are manageable. 

  1. Why it is necessary to start treatment early?

Research has established a fact that longer the duration of untreated illness, the worse will be the prognosis. Another research found that a maximum decline in functioning and cognitive skills appear during the first two years of illness. So if we are able to start treatment early, the outcome can be made better.

What is the outcome of schizophrenia after treatment?

1/5 patients have a good prognosis. They return to baseline medicine. Medicine can be stopped easily.

3/5 patients need medicine for a longer period of time. Although their symptoms not fully recover, they can live and earn independently with minor support from family.

1/5 patients, they need long term care and treatment. Independent living is difficult.

Case Study:

A young boy student of 10th grade was referred by a school teacher. She noticed a steady decline in studies. According to her report, he was behaving strangely in class and break time.  He used to remain isolated, collect pieces of newspaper and put them in his bag. His parents reported that he used to stare at walls most of the time. During the interview with the boy, he was uncomfortable and looking side by side. He reported he is forced to do a project by some agencies. He has to decode the hidden messages. These messages are in the form of letters written on papers. He also heard voices of a female. He described it as artificial intelligence. It gave him instructions about where to put those decoded messages. He was frightened that if he will not do that task, they will kill him and his family. 

After a detailed evaluation, he was diagnosed to be suffering from schizophrenia. The psychiatrist prescribed him medicine and educated the family regarding illness and the importance of taking medicine regularly. After three to four weeks his condition started improving.

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