SCHIZOPHRENIA

Introduction to schizophrenia

Schizophrenia is a group of severe mental disorders characterised by reality distortions resulting in unusual thought patterns and behaviours.

Because there is often little or no logical relationship between the thoughts and feelings of a person with schizophrenia, the disorder has often been called “split personality.” However, the condition should not be confused with multiple personality, which is a disorder in which the individual has two or more distinct personalities that dominate at different times

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Introduction to schizophrenia – cont’d

Schizophrenia is considered the most common and disabling of the psychotic disorders. Although it is a psychiatric disorder, it stems from a physiologic malfunctioning of the brain.

Affects all races, and is more prevalent in men than in women.

No cultural group is immune and persons with intelligence quotients of the genius level are not spared.

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Introduction to schizophrenia – cont’d

Schizophrenia occurs twice as often in people who are unmarried and divorced people as in those who are married or widowed. People with schizophrenia are more likely to be members of lower socioeconomic groups. In 1896 Emil Kraepelin originally called schizophrenia dementia praecox meaning “madness of the young” to differentiate it from manic-depressive psychosis due to the presence of hallucinations and delusions.

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Introduction to schizophrenia – cont’d

The term schizophrenia was coined by a German psychiatrist, Eugen Bleuler (1857–1939), in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception.

He defined the disorder through the presence of two groups of symptoms:

Primary symptoms – with 4As (i.e., flattened Affect, Autism, impaired Association of ideas and Ambivalence), and

Secondary symptoms – include delusions, hallucinations, and disorganized, idiosyncratic speech.

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Introduction to schizophrenia – cont’d

Affective disturbance refers to the person’s inability to show appropriate emotional responses.

Autistic thinking is a thought process in which the individual is unable to relate to others or to the environment.

Ambivalence refers to contradictory or opposing emotions, attitudes, ideas, or desires for the same person, thing, or situation.

Looseness of association is the inability to think logically. Ideas expressed have little, if any, connection and shift from one subject to another (Shives, 2005).

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Introduction to schizophrenia – cont’d

Due to stigmatization against people living with this disorder, in 2002 the Japanese Society of Psychiatry and Neurology changed the term for schizophrenia from mind-split-disease to Integration Disorder to reduce stigma (Kim and Berrios, 2001).

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DEFINITION(S)

• Schizophrenia is a disorder characterized by disturbances, for at least 6 months, in the thought (content and form), perception, affect, sense of self, volition, interpersonal relationships, and psychomotor behavior.

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• Schizophrenia is a mental disorderSchizophrenia is a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinationsSchizophrenia is a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoidSchizophrenia is a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusionsSchizophrenia is a mental disorder characterized by abnormalities in the perception or expression of reality. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking with significant social or occupational dysfunction.

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INCIDENCE

• Onset of symptoms typically occurs in late adolescence or young adulthood.
• Schizophrenia occurs equally in males and females, although typically appears earlier in men—the peak ages of onset are 20–28 years for males and 26–32 years for females.
• Around 1% of the population is affected.
• Diagnosis is based on the patient's self-reported experiences and observed behavior.
• No laboratory test for schizophrenia currently exists .

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INCIDENCE – cont’d

• The average life expectancyThe average life expectancy of people with the disorder is 10 to 12 years less than those without, due to increased physical health problems and a higher suicide rate (about 5%).

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• Social stigma has been identified as a major obstacle in the recovery of patients with schizophrenia with a large number of people believing that individuals with schizophrenia were “very likely” to do something violent against others.

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INCIDENCE – cont’d

• Common in urban areas with those who are unemployed, poor, and homeless.

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• Schizpohrenics form about half of the patients occupying mental hospital beds.

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• The prognosis worsens with each acute episode.

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AETIOLOGY

• Biological factors
• Biochemical (neurochemical) changes: Increased dopamine Increased dopamine activity in the mesolimbic pathway of the brain is consistently found in schizophrenic individuals.

The dopamine hypothesis posits that an excessive amount of the neurotramsmitter dopamine allows nerve impulses to bombard the mesolimbic pathway, the part of the brain normally involved in arousal and motivation. Normal cell communication is disrupted, resulting in the development of hallucinations and delusions.

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Norepinephrine and serotonin systems have also been implicated in the causation of schizophrenia.

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AETIOLOGY – cont’d

• Endocrine factors: Changes in prolactin, melatonin, and thyroid function have been found in schizophrenia.

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• Brain structural changes: CT, MRI, and postmortem studies have shown decreased volume and density in limbic and frontal areas in schizophrenic patients. Other medical imaging studies have also revealed various physical and physiological anomalies in some patients. Other research has focused on mistiming of neural responses to stimuli in the brain.

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AETIOLOGY – cont’d

• Prenatal: Causal factors are thought to initially come together in early neurodevelopment Causal factors are thought to initially come together in early neurodevelopment 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).

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AETIOLOGY – cont’d

There is now evidence that prenatal exposure to infections (i.e., prenatal exposure to influenza during the second trimester) 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.

Other gestational and birth complications, such as Rh factor incompatibility, as well as prenatal nutritional deficiencies, have been associated with schizophrenia.

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AETIOLOGY – cont’d

• Vitamin deficiency: The vitamin deficiency theory suggests that persons, who are deficient in vitamin B, namely B₁, B₆, and B₁₂, as well as in vitamin C, may become schizophrenic as a result of a severe vitamin deficiency.

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AETIOLOGY – cont’d

• Genetics: It has been noted that the closer the biological relationship between an individual and a person considered to be schizophrenic, the greater the disorder. This is based on data from family studies.

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Aetiology – genetics (cont’d)

• Family studies: A child born with one schizophrenic parent has about a 50% chance of developing schizophrenia. It is 90% if both parents are schizophrenics. There is 50% chance of developing the condition when a sibling is schizophrenic, i.e., non-twin siblings. Second degree relatives have 25% chances of suffering the illness; when no relative is affected with the illness, the chances are 2–3% of a family member developing the condition.

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Aetiology – genetics (cont’d)

• Twin and Adoption studies: Twin studies Twin studies and adoption studies have suggested a high level of heritability (the proportion of variation between individuals in a population that is influenced by genetic factors). According to these studies if one of the monozygotic (identical) twins suffers schizophrenia, there is about 90% chance of the other twin also developing the condition. For the dizygotic (non-identical) twins, there is near to 50% chance of the other catching the condition.

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AETIOLOGY of schizophrenia – cont’d

• Psychological Factors

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• Personality traits: Personality characteristics of an individual, such as withdrawn, extreme quietness and shyness, highly dependent and obedient, having temper tantrums, and always looking sad and miserable, is a recipe for schizophrenia.

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AETIOLOGY of schizophrenia – cont’d

• 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.

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AETIOLOGY of schizophrenia – cont’d

• Some cognitive features may reflect global cognitive deficits in memory, attention, problem-solving, executive function or social cognition, while others may be related to particular issues and experiences.

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AETIOLOGY of schizophrenia – cont’d

• Environmental/Social Factors

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• Recreational drug use: Although about half of all patients with schizophrenia use drugs or alcohol, a clear causal connection between drug use and schizophrenia has been difficult to prove. The two most often used explanations for this are “substance use causes schizophrenia” and “substance use is a consequence of schizophrenia”, and they both may be correct (Ferdinand, Sondeijker, van der Ende, Selten, Huizink, and Verhulst, 2005).

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AETIOLOGY of schizophrenia – cont’d

• 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.

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AETIOLOGY of schizophrenia – cont’d

• Social:

Social disadvantage found to be a risk factor, include:

• poverty,
• migration related to social adversity,
• racial discrimination,
• family dysfunction,
• unemployment
• poor housing conditions.

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AETIOLOGY of schizophrenia – cont’d

• Developmental factors – complication of the foetus during pregnancy may result in the condition, malnutrition, maternal drug use/alcoholism, asphyxia, infections, forceps delivery, etc.

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• Double bind theory – Schizophrenia is a consequence of abnormal patterns in family communication or a person is given mutually contradictory signals by another person.

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Double Bind as a Theory�

Bateson et al. (1956) proposed that schizophrenic symptoms are an expression of social interactions in which the individual is repeatedly exposed to conflicting injunctions, without having the opportunity to adequately respond to those injunctions, or to ignore them (i.e., to escape the field). For example, if a mother tells her son that she loves him, while at the same time turning her head away in disgust, the child receives two conflicting messages about their relationship on different communicative levels, one of affection on the verbal level, and one of animosity on the nonverbal level. It is argued that the child's ability to respond to the mother is incapacitated by such contradictions across communicative levels, because one message invalidates the other. Because of the child's vital dependence on the mother, Bateson et al. argue that the child is also not able to comment on the fact that a contradiction has occurred, i.e., the child is unable to metacommunicate (Bateson et al., 1956).

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PROGNOSTIC FACTORS

Prognosis indicates the likelihood of recovery from a disease. Factors which are responsible for a good prognostic outcome of schizophrenia are:

• Age of the patient – The older the patient, the more favorable the prognosis.
• The duration of illness – The shorter the duration prior to treatment, the better the outcome.
• The rapidity of development of the symptoms – Surprisingly, it has been found that the more speedily the symptoms develop, the faster do they respond to treatment; a very slow, insidious, and gradual onset of illness suggests a final poor outcome.

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PROGNOSTIC FACTORS – Cont’d

• A patient who had close friendships and multiple relationships prior to illness has a brighter chance with few or no such relationships.
• Life stress prior to onset – An episode brought on by a major identifiable life stress will respond more quickly than an episode without any obvious cause.
• Marital history – A patient with a stable and helpful marital partner has a favorable prognosis as compared to an unmarried patient.
• Educational history – The higher the level of education, the more are the chance of a patient coming rapidly to terms with the illness and handling the post-illness sequence.

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PROGNOSTIC FACTORS – Cont’d

• Occupational history – A patient with a good stable occupation or business prior to onset of illness will respond better than a patient who is jobless and economically unsound.

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• Family’s attitude towards the returning patient – Hostile behaviour by family members, or vice versa, excessive care and attention by them can undermine the patient’s sense of confidence and hamper recovery.

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PROGNOSTIC FACTORS – Cont’d

• Social support systems – A patient with a joint family and a staunch circle of friends who are ready lend a helping hand, is much better off than a lone man afflicted with the illness, whose relatives are in some far off land, and who has no one to turn to.

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• Organic brain damage – Presence of concurrent obvious brain damage (mental retardation, epilepsy, head injury, etc.) hinders the final adequate recovery from schizophrenia.

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PROGNOSTIC FACTORS – Cont’d

However, factors which may indicate a poor or bad prognosis include:

• Earlier age of onset
• Being a male
• A higher number of negative symptoms
• A family history of schizophrenia
• A low level of functioning prior to onset
• Poor or no support system
• A history of substance abuse

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RISK FACTORS

Certain factors seem to increase the risk of developing or triggering schizophrenia, including:

• Having a family history of schizophrenia
• Intrauterine exposure to viruses, toxins or malnutrition, particularly in the first and second trimesters
• Stressful life circumstances
• Older paternal age
• Taking psychoactive drugs during adolescence and young adulthood

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CLINICAL FEATURES

• Positive/Active Symptoms

The term positive symptom refers to symptoms that most individuals do not normally experience but are present in schizophrenia. They include

delusions,

hallucinations (auditory),

thought disorder,

disorganized behaviour,

These are typically regarded as manifestations of psychosis.

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CLINICAL FEATURES – cont’d

• Negative/Deficit symptoms

Common negative symptoms include:

flat or blunted affect and emotion,

poverty of speech (alogia),

inability to experience pleasure (anhedonia),

lack of desire to form relationships (asociality),

isolation (social withdrawal)

lack of motivation (avolition).

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CLINICAL FEATURES (negative symptoms) cont’d

Negative symptoms contribute more to poor quality of life, functional disability, and the burden on others than do positive symptoms.

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• A third symptom grouping, the disorganization syndrome, is sometimes described, and includes chaotic speech, thought, and behavior.

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Complications for Schizophrenia – cont’d

Because of disordered thought processes, the schizophrenic patient often neglects personal hygiene or ignores health needs. As a result, the patient has a shorter life expectancy than the general population.

5 TO 10 percent of schizophrenic patients commit suicide.

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Other complications include:

• Aggression
• Violence
• Violence against others
• Increased risk of substance abuse (exacerbating symptoms in some patients)

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Subtypes of schizophrenia

• Paranoid type:
• delusions and hallucinations are present
• but thought disorder, disorganized behavior, and affective flattening are absent.
• The individual is often tense, suspicious, and guarded,
• may be argumentative, hostile, angry and aggressive.
• At the workplace, he has the false notion that co-workers talk about him behind his back and laugh quietly as he passes by.

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Subtypes of schizophrenia

• Paranoid – cont’d
• Patient may refuse to eat meals served of the suspicion that the food is secretly poisoned. He may appeal to authorities for help.
• Grandiose delusions may also dominate the clinical picture. For instance, he believes himself anointed with holy oil, trumpets blared forth his appearance as a prophet. He has a message that will save the world, and sets about spreading it.

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Subtypes of schizophrenia

• Disorganized type: Named hebephrenic schizophrenia in the ICD.
• thought disorder and flat affect are present together.
• Onset of symptoms is usually before age 25 years, and the course is commonly chronic.
• delusions and hallucinations are present, they are relatively minor.
• bizarre behaviour, loosened associations, and
• inappropriate affect with periods of caricature of childish silliness and incongruous giggling (laughter).

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Subtypes of schizophrenia – cont’d

• Disorganized type (continued)
• Facial grimaces and bizarre mannerisms are common,
• communication is consistently incoherent.
• Personal appearance is generally neglected,
• social impairment is extreme.

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Subtypes of schizophrenia – cont’d

• Catatonic type:
• The patient may be almost immobile, or
• exhibit agitated, purposeless movement.
• Patient may scream, howl, beat his sides repeatedly, jump up, hop about or skitter back and forth.
• Words and phrase may be repeated hundreds of times (echolalia).
• He remains most part withdrawn, making little or no effort to interact with others.

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Subtypes of schizophrenia – cont’d

• Catatonic type (cont’d)

Symptoms can include:

• catatonic stupor: this is extreme immobility without evidence of absent or decreased consciousness.

The patient is also rigid and mute and only appears to be conscious as the eyes are open and follow surrounding objects (Gelder, Mayou and Geddes 2005).

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Example: The patient sits immobile in a chair for sixteen hours, staring fixedly, apparently unaware of other people or his own bodily needs.

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Subtypes of schizophrenia – cont’d

• Catatonic type – symptoms (cont’d)
• waxy flexibility: the patient remains in any position that s/he is placed.

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The patient is nearly or completely unresponsive to stimuli and remains immobile for long periods of time.

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Example: A schizophrenic man stands stock-still near his bed. When a psychiatrist lifts the man’s arm, it remains in the exact same position for hours after she lets go.

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Subtypes of schizophrenia – cont’d

• Catatonic type – symptoms (cont’d)
• catatonic excitement: this involves purposeless motor activity and agitation.

The patient shows impulsivity, destructive behaviour which urgently require physical and medical control because s/he is often destructive and violent to others, and his/her excitement can cause him/her to injure him/herself or to collapse from complete exhaustion.

Pernicious or acute lethal catatonia is the other name used to describe excited catatonia.

Example: The patient runs aimlessly through the dining hall due to an episode of catatonic excitement, knocking over objects without apparent regard, and ignoring all outside attempts to stop or redirect her.

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Subtypes of schizophrenia – cont’d

• Undifferentiated type

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• Psychotic symptoms are present but the criteria for paranoid, disorganized, or catatonic types have not been met.

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Subtypes of schizophrenia – cont’d

• Residual type
• positive symptoms are present at a low intensity only.
• This diagnostic category is used when the individual has a history of at least one previous episode of schizophrenia.
• At this stage, there is continuing evidence of the illness, although there are no prominent psychotic symptoms.
• symptoms may include social isolation, eccentric (strange/unusual) behaviour, impairment in personal hygiene and grooming, blunted or inappropriate affect, poverty of or overly elaborate speech, illogical thinking or apathy. For most part, however, the patient does little to attract any attention.

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Subtypes of schizophrenia – cont’d

The ICD-10 defines two additional subtypes.

• Post-schizophrenic depression
• The client may express depressed and manic behaviours with psychomotor retardation and suicidal ideation, as well as euphoria, grandiosity, and hyperactivity.
• To diagnose this disorder, the individual in addition to the above symptoms should exhibit delusions, hallucinations, incoherent speech, catatonic behaviour, or blunted or inappropriate affect.
• This disorder is also known as schizoaffective disorder
• (NB: Schizoaffective disorder: People with this illness have symptoms of both schizophrenia and a mood disorder, such as depression or bipolar disorder).

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Subtypes of schizophrenia – cont’d

The ICD-10 defines two additional subtypes (cont’d).

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• Simple schizophrenia

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• Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes, i.e., hallucinations and delusions may be absent.

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Other forms of psychotic disorders�

• Brief Psychotic Disorder

People with this illness have sudden, short periods of psychotic behavior, often in response to a very stressful event, such as a death in the family. Recovery is often quick -- usually less than a month.

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• Schizophreniform Disorder

People with this illness have symptoms of schizophrenia, but the symptoms last more than one month but less than six months.

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Other forms of psychotic disorders – cont’d

• Delusional Disorder

People with this illness have delusions involving real-life situations that could be true, such as being followed, being conspired against, or having a disease. These delusions persist for at least one month.

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• Shared Psychotic Disorder

This illness occurs when a person develops delusions in the context of a relationship with another person who already has his or her own delusion(s).

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Other forms of psychotic disorders – cont’d

• Psychotic Disorder due to a General Medical Condition

Hallucinations, delusions, or other symptoms may be the result of another illness that affects brain function, such as a head injury or brain tumor.

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• Substance-Induced Psychotic Disorder

This condition is caused by the use of or withdrawal from some substances, such as alcohol and crack cocaine, that may cause hallucinations, delusions, or confused speech.

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Other forms of psychotic disorders – cont’d

• Paraphrenia

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This is a type of schizophrenia that starts late in life and occurs in the elderly population.

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TREATMENT

• Antipsychotic medication,

e.g., Haldol, Thorazine/Largactil, Stelazine, etc., and newer medications (often called atypicals) such as Clozaril, Risperdal, and Zyprexa.

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• Education & support, for both ill individuals and families

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• Social skills training

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• Rehabilitation to improve activities of daily living

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• Vocational and recreational support

• Cognitive therapy

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