A complex, multifactorial, chronic, severe, disabling brain disorder, diagnosed in young adults at the time of the first psychotic episode of hallucinations and delusions.
Causes.
Table of Contents
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Genes and environment.
Genetic factors are,
- Runs in families.
- Has a 10% chance in first degree relatives. Second degree relatives have a higher chance (1%) than the general population. There is a 40-65% chance of occurrence in an identical twin of a person with schizophrenia.
Environmental factors are,
- Exposure to viruses.
- Malnutrition before birth.
- Problems during birth.
- Unknown psychosocial factors.
Interactions between genetic and environmental factors are necessary for the occurrence of schizophrenia.
2. Different brain structure and chemistry.
Imbalance in the chemical reactions involving neurotransmitters Dopamine and Glutamate maybe a cause.
Brains look different in small ways.
Eg: Larger ventricles, less grey matter, some areas show more or less activity.
Some differences of brain tissue may also be a cause.
Risk Groups.
- Family history of schizophrenia.
- Exposure to viruses and toxins or malnutrition while in the womb during the first and second trimesters.
- Inflammation or autoimmune diseases.
- Older age of the father.
- Psychoactive or psychotropic drugs during teen years and adulthood.
– Males and females have an equal chance of occurrence. But males develop the symptoms a little early in life.
– In most cases, this does not occur after 45 years of age.
– Rarely occurs in childhood. But awareness is increasing.
– It’s difficult to diagnose in teens as some symptoms show similarity with normal teenage behavior.
– All ethnic groups show similar rates of occurrence.
Symptoms.
A.) Positive Symptoms.
1.) Hallucinations.
Only the person can experience the sounds and the sensations, but the others cannot. It may involve any one of the five senses.
Auditory hallucinations are the most common. Most of the time, the person complains as “hearing voices”. These “voices” are mostly critical or abusive in nature and comes from someone the person knows.
Visual hallucinations are also relatively common.
2.) Delusions.
These are the false beliefs that are not based on reality.
Very common and occurs in more than 90% of cases.
These are,
- Delusions of persecution.
- Delusions of reference.
- Delusions of grandeur.
- Delusions of control.
3.) Thought Disorders.
Unusual or dysfunctional ways of thinking.
- Disorganized thinking (speech).
- Thought blocking.
- Make up meaningless words. (Neologisms.)
4.) Movement Disorders.
This may include,
- Resistance to instructions.
- Bizarre or inappropriate posture.
- Complete lack of movement.
- Excessive movement or agitated movements.
B.) Negative Symptoms.
Associated with disruption of normal emotions or behavior. They include,
- Emotional unresponsiveness. (Flat effect.)
- Social withdrawal.
- Lack of initiative or drive.
- Lack of pleasure in everyday life.
C.) Cognitive Symptoms.
These are subtle and therefore difficult to recognize as being part of the disorder.
They are,
- Poor executive functioning.
- Trouble focusing or paying attention.
- Trouble with logical thinking.
- Problems with memory.
- Confused and disordered speech.
These symptoms make it hard to earn a living and lead a normal life. They also lead to emotional distress in the person.
– All these symptoms of schizophrenia usually begin to appear during early adulthood.
– In case of men, they appear during early twenties.
– In case of women, they appear during late twenties and early thirties.
Diagnostic Criteria.
Diagnosis of schizophrenia is done according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) published by the American Psychiatric Association. (Tandon, R., et al., Definition and description of schizophrenia in the DSM-5, Schizophr. Res. (2013), http://dx.doi.org/ 10.1016/j.schres.2013.05.028)
The main focus of diagnosing schizophrenia is, to eliminate other mental disorders and to determine that the symptoms are only due to this disorder and not due to any substance abuse, medications or any other medical conditions.
a.) Two or more of the following symptoms, each of which must be present for a significant amount of time during a period of one month.
- Hallucinations.
- Delusions.
- Disorganized speech.
- Grossly disorganized or catatonic behavior.
- Negative symptoms.
b.) Social or occupational dysfunction.
Since the onset of the symptoms, there is a marked decrease in the major daily functioning of the person for a significant period of time.
c.) Continuous signs of disturbance persisting for at least six months.
d.) Schizoaffective and major mood disorders have to be excluded.
e.) Substance or general mood conditions have to be excluded.
f.) If there is a history of autism spectrum disorder or other communication disorders of childhood onset, the schizophrenia diagnosis is made only if hallucinations or delusions are present for at least one month.
Treatment.
A.) Antipsychotic Drugs.
1.) Typical or conventional drugs.
These are first generation drugs.
They control the positive symptoms.
2.) Atypical or new drugs.
These are the second generation drugs.
They control the positive and negative symptoms.
- Risperidone
- Clozapine
- Olanzapine
- Quetiapine
- Ziprasidone
- Aripiprazole
- Paliperidone
These atypical drugs have lesser side effects than the typical drugs and they can be managed successfully. Therefore, they are more preferred now.
Side effects are,
- Drowsiness.
- Postural dizziness.
- Blurred vision.
- Dry mouth.
- Constipation.
- Urinary retention.
- Muscle spasm.
- Tremors.
B.) Psychosocial Treatment.
1.) Rehabilitation.
Social and vocational training.
This includes job counselling and training, money management counselling, practice of communication skills.
2.) Family education.
The therapist has a role in helping the family members to learn coping strategies and problem solving skills that are required to take care of the patients and to make sure the patients stick to the medication and treatment plan at all times.
3.) Cognitive behavioral therapy. (CBT)
CBT focuses on the thinking and behavior of the patient.
It helps the patients to cope with the symptoms that are not controlled by medication and helps to reduce the severity of these symptoms. It also reduces the risk of relapse.
4.) Individual therapy.
This teaches the patients to take an active role in managing their illness on their own by helping them to cope with stress and to recognize warning signs of relapse of the condition.
5.) Self-help groups.
These are for patients and their family members. The members of these groups support each other to cope with the disorder.
Prognosis.
– Full recovery of these patients is not common.
– 5% of cases have a risk of suicide throughout their life time.
– Positive symptoms respond well to antipsychotic drugs while the other symptoms persist.
– Poor prognosis is seen in cases with,
- Family history.
- Early onset.
- Structural brain abnormalities.
- Prominent cognitive symptoms.