Schizophrenia

Schizophrenia is a mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucination, delusions and extremely disordered thinking and behavior that impairs daily functioning. People with schizophrenia often have problems doing well in society, at work, at school, and in relationships. They might feel frightened and withdrawn, and could appear to have lost touch with reality. Schizophrenia involves a psychosis, a type of mental illness in which a person can't tell what's real from what's imagined. At the time people with psychotic disorders lose touch with reality. The world may seem like a jumble of confusing thoughts, images and sounds. Their behavior may be very strange and even shocking. A sudden change in personality and behavior. Schizophrenia is a chronic heterogeneous syndrome of disorganized and bizarre thoughts, delusion, hallucination, inappropriate affect, cognitive deficits, and impaired psychosocial functioning. It is a psychotic disorder marked by severely impaired thinking, emotions and behaviors. The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-direction. The most intimate thoughts, feelings, and acts are often felt to be known by others, and explanatory delusions may develop, the effect that natural or supernatural forces are at work to influence the afflicted individual's thoughts and actions in ways that are often bizarre. The individual may see himself aur herself as the pivot of all that happens. Hallucinations are present especially auditory hallucination is common and may comment on the individual's behavior or thoughts is also present. Perception is frequently disturbed in the way of colors or sounds it may seem unduly vivid or altered in quality. In the schizophrenia irrelevant features of ordinary things may appear more important than the whole object or situations. In the characteristic schizophrenic disturbance of thinking, peripheral and irrelevant features of total concept, which are inhibited in normal directed mental activity, are brought to the fore and utilized in place of those that are relevant and appropriate to the situation. Thus, thinking becomes vague, elliptical and obscure, and its expression in speech sometimes incomprehensible. In the schizophrenia there is a series of thoughts or ideas are present which is called train of thoughts, which result incoherence or irrelevant speech. Catatonic behavior such as excitement, posturing, waxy flexibility, negativism, mutism and stupor type behaviors are present in the schizophrenic patient. There is a negative symptom such as marked apathy, paucity of speech, and blunting affect are present in schizophrenia. Most of the schizophrenics, are unable to understand sensory stimuli and may have enhanced perception of sounds, colors and other features of their environment. They withdraw themselves from the interactions with other people and loss their ability to take care of personnel needs.

Types of schizophrenia-

There are several types of schizophrenia -

Paranoid Schizophrenia-

 This is the commonest type of the schizophrenia in most parts of the world. Patients are usually preoccupied with paranoid delusions or auditory hallucinations. Cognitive function is usually preserved. Someone experiencing a paranoid delusion may believe they're being chased, followed, watched, plotted against or poisoned, often by a family members and friends. Some people who experience delusions find different meaning in everyday events.

Hebephrenic Schizophrenia-

 It is also called disorganized schizophrenia which is one of the subtypes of schizophrenia, characterized by disorganized thought, behavior and speech which affects in emotional regulation. People living with disorganized schizophrenia often shows little or no emotions in their facial expressions, voice tone or mannerism. Disorganized schizophrenia is associated with early onset, between the ages of 15-25yrs. Earlier age of onset is traditionally associated with a worse prognosis due to lower educational achievement, more prominent negative symptoms and cognitive impairment. This is the type which has the worst outcomes and prognosis. Only early detection, diagnosis and treatment of the disorder contributes to better outcomes.

Catatonic Schizophrenia-

 It is characterized by severe disturbances in movement and a marked lack of responsiveness to the outside world.at one end of the extreme they cannot speak, move or respond. At the other end of the extreme they are over excited or hyperactive mimicking sounds or movements around them. Other symptoms are, uncooperative which means they resist any attempt to move them, they may say absolutely nothing and won't listen to any instructions. The patient maintained strange movements, his posture may be unusual or inappropriate. With catatonic schizophrenia patients can stay immobile for long periods of time, in positions that we may think look extremely uncomfortable.

Residual Schizophrenia-

When people have a past history of positive schizophrenia symptoms but now only having lingering negative symptoms or none at all. These lingering symptoms may include poor attention, some mental disorganization, and emotional withdrawal. It means that the patient does not have acute psychosis, but some symptoms of schizophrenia remain. Largely negative symptoms are seen, such as flat affect, social withdrawal and loose associations. Prominent delusion and hallucinations are not present.

Undifferentiated Schizophrenia-

The patient meets the criteria for a diagnosis of schizophrenia but does not meet the criteria for a specific type. Or the patient meets the criteria for multiple types of schizophrenia. No one type appears to be dominant.

Simple Schizophrenia-

It is one of the subtypes which is the most difficult to identified. It is characterised by early onset, very insidious and progressive course, presence of characteristic negative symptoms of residual schizophrenia such as marked social withdrawal, shallow emotional response, with loss of initiative and drive, aimless wondering. Delusions and hallucinations are usually absent, and if present they are short lasting and poorly systematized.

Post - Schizophrenic Depression-

Some schizophrenic patients develop depressive features within 12 months of an acute schizophrenia. The depressive features develop in the presence of residual or active features of schizophrenia and are associated with an increased risk of suicide.

Symptoms

In persons with schizophrenia, the incidence of severe psychotic symptoms often decreases as the person become older. Not taking medications as prescribed, the use of alcohol or any other illicit drugs, and stressful situations may increase symptoms.

 Symptoms fall into three major categories:

            Cognition is another area of functioning that is affected in schizophrenia leading to problems with attention, concentration, memory and educational performance is also get affected.

Prevalence 

According to the world (mental) health report lifetime prevalence of schizophrenia ranges from 0.6% to 1.9%, with an average of approximately 1%. The worldwide prevalence of schizophrenia is remarkably similar among all cultures. Schizophrenia most commonly has its onset in late adolescence or early adulthood and rarely occurs before adolescence or after the age of 40 years. The prevalence of schizophrenia is equal in males and females.

Causes of schizophrenia

The causes of schizophrenia is currently unknown. No one knows the exact causes of schizophrenia, but multiple possible factors have been discovered.

Genetic factors

 A strong genetic factor exists for the development of schizophrenia. It occurs in 1% of general population, however these increases to 10% if a 1^st degree relative has a history of schizophrenia. Risk of developing schizophrenia further increased to 40% when both parents have a history of schizophrenia. In a twins monozygotic twins have demonstrated a 48% risk of developing schizophrenia if one twins has the disease.

Brain chemical imbalance-

The dopamine hyperactivity in the brain is responsible for psychotic symptoms present in schizophrenia. While dopamine hyperactivity is present in mesolimbic pathway, other areas of the brain such as the prefrontal, frontal and temporal cortices have decrease activity during acute psychosis.

Other neurotransmitters thought to be involved in schizophrenia include 5-HT, glutamate. The role of glutamate is also being evaluated because one of its major functions is to regulate dopamine activity.

Neurodevelopmental Factor-

Schizophrenia occurs as a result of an in uterodisturbance during pregnancy. Potential causes of this disturbance include upper respiratory infection, obstetric complication and neonatal hypoxia.

Psychosocial Factor-

In these social factors like stress, poor interpersonal skills, conflicting between family, communication and various socio- economic influences are linked to development of schizophrenia.

Diagnosis Criteria

International Classification of Diseases 10

Under ICD 10 schizophrenia comes under F 20 to F20.9

Schizophrenia is the commonest and most important disorder is this group. The schizophrenic disorders are characteristic distortions of thinking and perception, and by inappropriate or blunted affect. Certain cognitive deficits may involve in the course of time.

Diagnostic criteria- For a definitive diagnosis the following symptoms should be present

a)     Thought eco, thought insertion or withdrawal, thought broadcasting.

b)     Delusion of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception;

c)     Hallucinatory voices giving a running commentary on the patient's behavior, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;

d)     Persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities.

e)     Persistent hallucinations in any modality, when accompanied either by fleeting or half- formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months or months on end

f)       Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;

g)     Catatonic behavior, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor;

h)     Negative symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;

i)        A significant and consistent change in the overall quality of some aspects of personal behavior, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

Diagnostic Guidelines-

      The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed as (a) to (d) above, or symptoms from at least two of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more.

Risk Factors

Researches believe that number of genetic and environmental factors contribute to causation, and life stressors may play a role in the start of symptoms and their course. Since multiple factors may contribute, scientists cannot yet be specific about the exact cause in each individual case.

Treatment for schizophrenia

      Schizophrenia requires lifelong treatment, even when symptoms have subsided. Treatment with medications and psychosocial therapy can help manage the condition. In some cases, hospitalization may be also needed.

A psychiatrist experienced in treating schizophrenia usually guides treatment. There is a team for the treatment of the schizophrenia. In this team psychologist, psychiatrist, clinical psychologist, social workers, occupational therapists, psychotherapist, and community mental heath nurses are included for take care of the patients. This team is called community mental health teams (CMHTs). The goal of the CMHT is to provide day to day support and treatment while ensuring you have as much independence as possible.

Medications

Medications are the cornerstone of schizophrenia treatment, and antipsychotic medications are the most commonly prescribed drugs. They're thought to control symptoms by affecting the neurotransmitter dopamine. The goal of treatment with antipsychotic medications is to effectively manage signs and symptoms at the lowest possible dose.

Psychological treatment

Once psychosis recedes, in addition to continuing on medication, psychological and psychosocial treatment is also important. Psychological treatment can help people with schizophrenia cope with the symptoms of hallucinations or delusions better. They can also help treat some of the negative symptoms of schizophrenia, such as apathy or a lack of enjoyment and interest in things you used to enjoy. Psychosocial treatments for treatments are best for the schizophrenia when they're combined with antipsychotic medication.

Common psychological treatments for schizophrenia are:

*        Cognitive behavioral therapy

*        Social skills training

*        Individual therapy

*        Family therapy

*        Art therapy

*        Group therapy

*        Vocational rehabilitation and supported employment

Author: Pooja Maurya, M.Phil. Clinical Psychology,  1st year Trainee under the supervision of Dr. Ranjita, Assistant Professor of Clinical Psychology at CIIMHANS, Chattisgarh.