Alternative Names:
Blues; Discouragement; Gloom; Mood changes; Sadness; Melancholy
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Definition:
Schizophrenia is a severe, lifelong brain disorder. People who have it may hear voices, see things that aren’t there or believe that others are reading or controlling their minds. In men, symptoms usually start in the late teens and early 20s. They include hallucinations, or seeing things, and delusions such as hearing voices. For women, they start in the mid-20s to early 30s.
It is described a mental illness characterized by impairments in the perception or expression of reality, most commonly manifesting as auditory hallucinations, paranoid or bizarre delusions or disorganized speech and thinking in the context of significant social or occupational dysfunction. Onset of symptoms typically occurs in young adulthood, with approximately 0.4–0.6% of the population affected. Diagnosis is based on the patient’s self-reported experiences and observed behavior. No laboratory test for schizophrenia exists.
Studies suggest that genetics, early environment, neurobiology and psychological and social processes are important contributory factors. Current psychiatric research is focused on the role of neurobiology, but a clear organic cause has not been found. Due to the many possible combinations of symptoms, there is debate about whether the diagnosis represents a single disorder or a number of discrete syndromes. For this reason, Eugen Bleuler termed the disease the schizophrenias (plural) when he coined the name. Despite its etymology, schizophrenia is not synonymous with dissociative identity disorder, previously known as multiple personality disorder or split personality; in popular culture the two are often confused.
Increased dopaminergic activity in the mesolimbic pathway of the brain is a consistent finding. The mainstay of treatment is pharmacotherapy with antipsychotic medications; these primarily work by suppressing dopamine activity. Dosages of antipsychotics are generally lower than in the early decades of their use. Psychotherapy, vocational and social rehabilitation are also important. In more serious cases—where there is risk to self and others—involuntary hospitalization may be necessary, though hospital stays are less frequent and for shorter periods than they were in previous years.
The disorder is primarily thought to affect cognition, but it also usually contributes to chronic problems with behavior and emotion. People diagnosed with schizophrenia are likely to be diagnosed with comorbid conditions, including clinical depression and anxiety disorders; the lifetime prevalence of substance abuse is typically around 40%. Social problems, such as long-term unemployment, poverty and homelessness, are common and life expectancy is decreased; the average life expectancy of people with the disorder is 10 to 12 years less than those without, owing to increased physical health problems and a high suicide rate.
Schizophrenia affects people from all walks of life, usually young people between the ages of 15 and 30. Not everyone will experience the same symptoms, but some symptoms of schizophrenia, such as hearing voices, are common to many. Schizophrenia alters the way people think and feel, so that perceptions may be changed and thinking can be disturbed. This is very disabling for them and very distressing for their families, who often become the primary caregivers.
With modern medical treatment, opportunities for rehabilitation, and the support of family and friends, schizophrenia need not be as feared as it was in the past.
Signs and symptoms:-
A person experiencing schizophrenia may demonstrate symptoms such as disorganized thinking, auditory hallucinations, and delusions. In severe cases, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation; these are signs of catatonia. The current classification of psychoses holds that symptoms need to have been present for at least one month in a period of at least six months of disturbed functioning. A schizophrenia-like psychosis of shorter duration is termed a schizophreniform disorder. No one sign is diagnostic of schizophrenia, and all can occur in other medical and psychiatric conditions.
Social isolation commonly occurs and may be due to a number of factors. Impairment in social cognition is associated with schizophrenia, as are the active symptoms of paranoia from delusions and hallucinations, and the negative symptoms of apathy and avolition. Many people diagnosed with schizophrenia avoid potentially stressful social situations that may exacerbate mental distress.
Late adolescence and early adulthood are peak years for the onset of schizophrenia. These are critical periods in a young adult’s social and vocational development, and they can be severely disrupted by disease onset. To minimize the effect of schizophrenia, much work has recently been done to identify and treat the prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset of symptoms, but may be present longer. Those who go on to develop schizophrenia may experience the non-specific symptoms of social withdrawal, irritability and dysphoria in the prodromal period, and transient or self-limiting psychotic symptoms in the prodromal phase before psychosis becomes apparent.
The symptoms of schizophrenia fall into three broad categories:
Positive symptoms are unusual thoughts or perceptions, including hallucinations, delusions, thought disorder, and disorders of movement.
Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life. These symptoms are harder to recognize as part of the disorder and can be mistaken for laziness or depression.
Cognitive symptoms (or cognitive deficits) are problems with attention, certain types of memory, and the executive functions that allow us to plan and organize. Cognitive deficits can also be difficult to recognize as part of the disorder but are the most disabling in terms of leading a normal life.
Other symptoms include:
*Unusual thoughts or perceptions
*Disorders of movement
*Difficulty speaking and expressing emotion
*Problems with attention, memory and organization
Causes:-
No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role. Medicines can relieve many of the symptoms, but it can take several tries before you find the right drug. You can reduce relapses by staying on your medicine for as long as your doctor recommends. With treatment, many people improve enough to lead satisfying lives.
While the reliability of the diagnosis introduces difficulties in measuring the relative effect of genes and environment (for example, symptoms overlap to some extent with severe bipolar disorder or major depression), evidence suggests that genetic and environmental factors can act in combination to result in schizophrenia. Evidence suggests that the diagnosis of schizophrenia has a significant heritable component but that onset is significantly influenced by environmental factors or stressors. The idea of an inherent vulnerability (or diathesis) in some people, which can be unmasked by biological, psychological or environmental stressors, is known as the stress-diathesis model. The idea that biological, psychological and social factors are all important is known as the “biopsychosocial” model.
Genetic
Estimates of the heritability of schizophrenia tend to vary owing to the difficulty of separating the effects of genetics and the environment although twin studies have suggested a high level of heritability. It is likely that schizophrenia is a condition of complex inheritance, with several genes possibly interacting to generate risk for schizophrenia or the separate components that can co-occur leading to a diagnosis. Recent work has suggested that genes that raise the risk for developing schizophrenia are non-specific, and may also raise the risk of developing other psychotic disorders such as bipolar disorder
Prenatal
It is thought that causal factors can initially come together in early neurodevelopment, including during pregnancy, to increase the risk of later developing schizophrenia. One curious finding is that people diagnosed with schizophrenia are more likely to have been born in winter or spring, (at least in the northern hemisphere). There is now evidence that prenatal exposure to infections increases the risk for developing schizophrenia later in life, providing additional evidence for a link between in utero developmental pathology and risk of developing the condition
Social
Living in an urban environment has been consistently found to be a risk factor for schizophrenia. Social disadvantage has been found to be a risk factor, including poverty and migration related to social adversity, racial discrimination, family dysfunction, unemployment or poor housing conditions. Childhood experiences of abuse or trauma have also been implicated as risk factors for a diagnosis of schizophrenia later in life. Parenting is not held responsible for schizophrenia but unsupportive dysfunctional relationships may contribute to an increased risk
Psychological
A number of psychological mechanisms have been implicated in the development and maintenance of schizophrenia. Cognitive biases that have been identified in those with a diagnosis or those at risk, especially when under stress or in confusing situations, include excessive attention to potential threats, jumping to conclusions, making external attributions, impaired reasoning about social situations and mental states, difficulty distinguishing inner speech from speech from an external source, and difficulties with early visual processing and maintaining concentration.Some cognitive features may reflect global neurocognitive deficits in memory, attention, problem-solving, executive function or social cognition, while others may be related to particular issues and experiences. Despite a common appearance of “blunted affect”, recent findings indicate that many individuals diagnosed with schizophrenia are highly emotionally responsive, particularly to stressful or negative stimuli, and that such sensitivity may cause vulnerability to symptoms or to the disorder. Some evidence suggests that the content of delusional beliefs and psychotic experiences can reflect emotional causes of the disorder, and that how a person interprets such experiences can influence symptomology. Further evidence for the role of psychological mechanisms comes from the effects of therapies on symptoms of schizophrenia.
Neural
Studies using neuropsychological tests and brain imaging technologies such as fMRI and PET to examine functional differences in brain activity have shown that differences seem to most commonly occur in the frontal lobes, hippocampus, and temporal lobes. These differences have been linked to the neurocognitive deficits often associated with schizophrenia. The role of antipsychotic medication, which nearly all those studied had taken, in causing such abnormalities is also unclear.
There have also been findings of differences in the size and structure of certain brain areas in schizophrenia, starting with the discovery of ventricular enlargement in those for whom negative symptoms were most prominent. However, this has not proven particularly reliable on the level of the individual person, with considerable variation between patients. More recent studies have shown various differences in brain structure between people with and without diagnoses of schizophrenia. However, as with earlier studies, many of these differences are only reliably detected when comparing groups of people, and are unlikely to predict any differences in brain structure of an individual person with schizophrenia.
Treatment and Services:-
The concept of a cure as such remains controversial, as there is no consensus on the definition, although some criteria for the remission of symptoms have recently been suggested.The effectiveness of schizophrenia treatment is often assessed using standardized methods, one of the most common being the positive and negative syndrome scale (PANSS). Management of symptoms and improving function is thought to be more achievable than a cure. Treatment was revolutionized in the mid 1950s with the development and introduction of chlorpromazine. A recovery model is increasingly adopted, emphasizing hope, empowerment and social inclusion.Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups.
In many non-Western societies, schizophrenia may only be treated with more informal, community-led methods. The outcome for people diagnosed with schizophrenia in non-Western countries may actually be better than for people in the West.The reasons for this effect are not clear, although cross-cultural studies are being conducted.
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Medication
The mainstay of psychiatric treatment for schizophrenia is an antipsychotic medication. These can reduce the “positive” symptoms of psychosis. Most antipsychotics take around 7–14 days to have their main effect.
Psychological and social interventions:
Psychotherapy is also widely recommended and used in the treatment of schizophrenia, although services may often be confined to pharmacotherapy because of reimbursement problems or lack of training.
Cognitive behavioral therapy (CBT) is used to reduce symptoms and improve related issues such as self-esteem, social functioning, and insight. Although the results of early trials were inconclusive, more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia. Another approach is cognitive remediation therapy, a technique aimed at remediating the neurocognitive deficits sometimes present in schizophrenia. Based on techniques of neuropsychological rehabilitation, early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by fMRI.A similar approach known as cognitive enhancement therapy, which focuses on social cognition as well as neurocognition, has shown efficacy.
Family Therapy or Education, which addresses the whole family system of an individual with a diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is longer-term. Aside from therapy, the impact of schizophrenia on families and the burden on carers has been recognized, with the increasing availability of self-help books on the subject. There is also some evidence for benefits from social skills training, although there have also been significant negative findings. Some studies have explored the possible benefits of music therapy and other creative therapies.
How Families Can Help:
The importance of family involvement in care has been well-documented and includes
*Decreased rates of hospitalization & relapse;
*Enhanced adherence to treatment choices;
*Increased rates of recovery;
*Decreased involvement with the criminal justice system; and
*Savings to the mental health system.
Families can help by learning about the illness, symptoms, and signs of relapse. Depending on the situation, you may be able to keep track of appointments, medications, side effects in a journal so you and your relative can look back and understand what works and what doesn’t. Encourage participation in hobbies, support and social groups. But most of all, be supportive and let your relative know that you are there for them.
The Soteria model is alternative to inpatient hospital treatment using a minimal medication approach. It is described as a milieu-therapeutic recovery method, characterized by its founder as “the 24 hour a day application of interpersonal phenomenologic interventions by a nonprofessional staff, usually without neuroleptic drug treatment, in the context of a small, homelike, quiet, supportive, protective, and tolerant social environment.” Although research evidence is limited, a 2008 systematic review found the programme equally as efffective as treatment with medication in people diagnosed with first and second episode schizophrenia.
Other
Electroconvulsive therapy is not considered a first line treatment but may be prescribed in cases where other treatments have failed. It is more effective where symptoms of catatonia are present, and is recommended for use under NICE guidelines in the UK for catatonia if previously effective, though there is no recommendation for use for schizophrenia otherwise. Psychosurgery has now become a rare procedure and is not a recommended treatment for schizophrenia.
Service-user led movements have become integral to the recovery process in Europe and America; groups such as the Hearing Voices Network and the Paranoia Network have developed a self-help approach that aims to provide support and assistance outside the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for mental illness or mental health, they aim to destigmatize the experience and encourage individual responsibility and a positive self-image. Partnerships between hospitals and consumer-run groups are becoming more common, with services working toward remediating social withdrawal, building social skills and reducing rehospitalization.
Prognosis:-
Numerous international studies have demonstrated favorable long-term outcomes for around half of those diagnosed with schizophrenia, with substantial variation between individuals and regions. One retrospective study found that about a third of people made a full recovery, about a third showed improvement but not a full recovery, and a third remained ill. A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years. A 5-year community study found that 62% showed overall improvement on a composite measure of symptomatic, clinical and functional outcomes. Rates are not always comparable across studies because an exact definition of what constitutes recovery has not been widely accepted, although standardized criteria have been suggested.
The World Health Organization conducted two long-term follow-up studies involving more than 2,000 people suffering from schizophrenia in different countries. These studies found patients have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (USA, UK, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia), despite the fact antipsychotic drugs are typically not widely available in poorer countries, raising questions about the effectiveness of such drug-based treatments.
Several factors are associated with a better prognosis: Being female, acute (vs. insidious) onset of symptoms, older age of first episode, predominantly positive (rather than negative) symptoms, presence of mood symptoms and good premorbid functioning. Most studies done on this subject, however, are correlational in nature, and a clear cause-and-effect relationship is difficult to establish. Evidence is also consistent that negative attitudes towards individuals with schizophrenia can have a significant adverse impact. In particular, critical comments, hostility, authoritarian and intrusive or controlling attitudes (termed high ‘Expressed emotion’ or ‘EE’ by researchers) from family members have been found to correlate with a higher risk of relapse in schizophrenia across cultures.
Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose
Resources:
http://www.nlm.nih.gov/medlineplus/schizophrenia.html
http://www.world-schizophrenia.org/
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