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January 09, 2020 Thursday 03:40:23 PM IST

Overcoming Schizophrenia

Personal

Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality. Although schizophrenia is not as common as other mental disorders, the symptoms can be very disabling.

It is a complex syndrome which is chronic and has heterogeneous combination of symptoms. The symptoms of schizophrenia can be divided into ‘positive’, ‘negative’ and ‘cognitive’ categories. Positive symptoms are behaviours and thoughts that are not normally present and consists of delusions, hallucinations and disorganized speech andbehaviour defining the psychotic stage a state of loss of contact with reality.Negative symptoms include social withdrawal, affective flattening, anhedonia (the inability to feel pleasure), reduced talk, diminished initiative and energy. Cognitive symptoms are expressed as a broad set of cognitive dysfunctions.

The onset of the illness is referred to as the prodromal phase (that is,before the manifestation of the first psychotic episode). It generally begins in the early adolescent years and precedes the onset of psychotic symptoms by >10 years and consists of a decline in cognitive and social functioning.

Patients with schizophrenia generally experience serious impairments in maintaining socialrelationships, sustaining employment and living independently. These deficits typically persist after patientsachieve remission from psychotic symptoms. However,a combination of antipsychotic medication and psychosocial interventions can increase the quality of life (QOL) and can enable independent living. Functional outcomes largely depend on thepresence and severity of cognitive and negative symptoms at disease onset.


Signs and Symptoms

Symptoms of schizophrenia usually start between ages 16 and 30. In rare cases, children have schizophrenia too.The symptoms fall into three categories: positive, negative, and cognitive.

Positive symptoms: “Positive” symptoms are psychotic behaviours not generally seen in healthy people. People with positive symptoms may “lose touch” with some aspects of reality. Symptoms include:

  • Hallucinations
  • Delusions
  • Thought disorders (unusual or dysfunctional ways of thinking)
  • Movement disorders (agitated body movements)

Negative symptoms: “Negative” symptoms are associated with disruptions to normal emotions and behaviours. Symptoms include:


  • “Flat affect” (reduced expression of emotions via facial expression or voice tone)
  • Reduced feelings of pleasure in everyday life
  • Difficulty beginning and sustaining activities
  • Reduced speaking

Cognitive symptoms: For some patients, the cognitive symptoms of schizophrenia are subtle, but for others, they are more severe and patients may notice changes in their memory or other aspects of thinking. Symptoms include:

  • Poor “executive functioning” (the ability to understand information and use it to make decisions)
  • Trouble focusing or paying attention
  • Problems with “working memory” (the ability to use information immediately after learning it)

Risk Factors

There are several factors that contribute to the risk of developing schizophrenia.This includes complications during intrauterine life, abnormalfoetal growth and complications at delivery and child birth. There is an overrepresentation of the disease in people who were born in late winter and spring (an increase of 7–10%). None of the explanations for this phenomenon have been firmly established but a possibility of maternal infections and malnutrition (folic acid, vitamin D deficiency etc) is being postulated. High paternal age is identified as a risk factor, but it’s not sure whether the late age at fatherhood is because of having any biological vulnerability for the disease.

Genes and environmentScientists have long known that schizophrenia sometimes runs in families. However, there are many people who have schizophrenia who don’t have a family member with the disorder and conversely, many people with one or more family members with the disorder who do not develop it themselves.


Scientists believe that many different genes may increase the risk of schizophrenia, but that no single gene causes the disorder by itself. It is not yet possible to use genetic information to predict who will develop schizophrenia.

Scientists also think that interactions between genes and aspects of the individual’s environment are necessary for schizophrenia to develop. Environmental factors may involve:

  • Exposure to viruses
  • Malnutrition before birth
  • Problems during birth
  • Psychosocial factors

Males are more prone to develop the illness and are also are said to have an earlier age at onset and a more severe form of the illness when compared to females. The risk of developing schizophrenia is found to be greater in those born or brought up exclusively in urban areas. Probably because of the lack of social support or increased exposure to discrimination, there is increased risk of the disease developing among migrants. Persistent abuse of amphetamine, methamphetamine and cocaine may produce a state similar to schizophrenia. Cannabis can precipitate transient psychotic symptoms and can also exacerbate existing psychotic symptoms. Childhood adversities including physical abuse, sexual abuse, maltreatment and bullying are also said to be risk factors.

Schizophrenia is a highly heritable disease to the extent that when both parents are affected you have 45 % chance of getting the disease. With a single parent or sibling having the disease the risk increases to 15%. The molecular and cellular alterations in schizophrenia has been studied using the advances in neuroimaging techniques.


Different brain chemistry and structure: Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters (substances that brain cells use to communicate with each other) dopamine and glutamate, and possibly others, plays a role in schizophrenia.Some experts also think problems during brain development before birth may lead to faulty connections. The brain also undergoes major changes during puberty, and these changes could trigger psychotic symptoms in people who are vulnerable due to genetics or brain differences.

Treatments and Therapies

Because the causes of schizophrenia are still unknown, treatments focus on eliminating the symptoms of the disease. Treatments include:


Antipsychotics

Antipsychotic medications are usually taken daily in pill or liquid form. Some antipsychotics are injections that are given once or twice a month. Some people have side effects when they start taking medications, but most side effects go away after a few days. Doctors and patients can work together to find the best medication or medication combination, and the right dose.

Psychosocial Treatments

These treatments are helpful after patients and their doctor find a medication that works. Learning and using coping skills to address the everyday challenges of schizophrenia helps people to pursue their life goals, such as attending school or work. Individuals who participate in regular psychosocial treatment are less likely to have relapses or be hospitalized


Once we think about preventive approaches psychosocial interventions may redirect a young person who is otherwise predisposed to schizophrenia towards a trajectory of social engagement, educational completion and independent living. The frank psychotic state is often preceded by a prodromal phase (80-90% cases) or attenuated psychosis characterised by subtle changes in belief, thought and perception can be considered as clinically high risk (CHR) group. The presence of a family history of schizophrenia in the context of a recent and substantial decline in functioning also labels someone as CHR. Identifying them and starting treatment with drugs or psychosocial interventions can have an important role in preventing the progress of the illness.

The cornerstone of the treatment of the disease is a group of drugs called antipsychotics. The treatment targets various domains of symptoms (positive, negative and cognitive, mood symptoms, suicidality, QOL, and social, academic and vocational functioning). Other biological interventions like Electro Convulsive Therapy (ECT) commonly known as shock treatment; transcranial magnetic stimulation is very safe and are even useful in cases that have not responded adequately to drugs. Poor compliance, delay in taking treatment after onset of illness, poor functioning before the onset of illness itself etc are some of the predictors of poor response to treatment. By addressing the stigma and the discrimination the quality of life of such patients can be further improved.

How can I help someone I know with schizophrenia?

Caring for and supporting a loved one with schizophrenia can be hard. It can be difficult to know how to respond to someone who makes strange or clearly false statements. It is important to understand that schizophrenia is a biological illness.

How to help a loved person with schizophrenia?
  • -Get them treatment and encourage them to stay in treatment
  • -Remember that their beliefs or hallucinations seem very real to them
  • -Tell them that you acknowledge that everyone has the right to see things their own way
  • -Be respectful, supportive, and kind without tolerating dangerous or inappropriate behaviour
  • -Check to see if there are any support groups in your area


Psychosocial interventions like supported employment or supported education, family psycho-education, cognitive remediation and assertive community treatment have all been shown to improve outcomes. If a John Nash can recover from Schizophrenia and win the Nobel Prize, then there is hope for everyone!


Prof Roy Abraham Kallivayalil & Dr Soumya P Thomas

*Prof. Roy Abraham Kallivayalil MD,DPM
Secretary General, World Psychiatric Association   
Professor & Head, Dept of Psychiatry

Pushpagiri Institute of Medical Sciences,  

Tiruvalla, Kerala- 689 101, India

                   &

**Dr Soumya P Thomas MD

Senior Resident

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