Schizophrenia

Understanding Schizophrenia
Schizophrenia can have a devastating negative impact on the social development of the patient and social relationships especially within the family circles.
Making the Diagnosis of Schizophrenia
The diagnosis of schizophrenia is based on certain categories of observations/experiences. These include:
1. A given set of symptoms that must have existed for a significant proportion of the previous one month if not treated or less if treated.
2. Social and occupational deterioration along several parameters.
3. Chronicity of at least six months since the illness process started.
It is also a requirement for the diagnosis of schizophrenia that the above conditions should not be attributed primarily to medical conditions, substance abuse, or other psychiatric conditions.
Features of Schizophrenia
Hallucinations
The general definition of a hallucination is a perception without an external stimulus. In hallucinations, one sees things, hear voices, taste, smell, or feel things that do not exist in reality---that is, other people cannot experience them, yet to you they are as real as if they existed in reality---that is, you are not pretending.
A Word of Caution
A hallucinated person is not pretending. They actually hear the voices. Therefore, do not argue with them to the effect that there is indeed no voice since nobody else can hear it. They find that kind of argument very offensive because you are by implication telling them that they are “mad.”
Delusions
Delusions are the other main symptoms of schizophrenia. A delusion is normally defined as a false belief that is held with absolute conviction of its truth although such a belief is not in conformity with the person’s culture or level of education. In other words, what is judged to be an abnormal belief is so judged using what others of some cultural background and educations consider to be an acceptable possibility.
Disorders of Thought(Thinking) and Speech
Schizophrenic patients may talk in a way that the listener has difficulty following. Under normal circumstances we follow what other people are saying if they talk at a pace that is not too fast and not too slow and also one in which their speech is jointed---that is, what they are saying is logically connected with what was said just before and what will be said next.
You can imagine the confusion to the listener if a person uttered five different sentences that were not related at all! Or even if related, they were said so fast you could not connect them or said so slowly as if they belonged to different compartments.
You may also be unable to follow what the patient is saying if he interjects his speech with words that do not belong to any known spoken language and whose meanings are probably only known to the person speaking. Or it could be that you are not able to really understand what the patient is saying because he is not able to go straight to the point he wants to make because he goes around what he really wants to say by telling stories that are not really relevant to the point they want to make.
Disorders of Emotions In Schizophrenia
There are several disorders of emotions that are associated with schizophrenia.
1. Some schizophrenic patients have flattened and blunted affect that does not change with the mood of what is happening around them. It is like they are devoid of feelings. Their mood will remain the same irrespective of whether or not the mood of the people around is one of happiness or sadness. It is like whatever happens, they never laugh or cry. This symptom is known as blunted or flat affect. This is a serious symptom of schizophrenia since it is hardly affected by drugs or most treatment for schizophrenia. It is regarded as one of the negative symptoms of schizophrenia.
2. Other schizophrenic patients express emotions that are totally contrary to what is expected. For example, just imagine how out of tune a person can be when in a funeral when all people are crying or showing feelings of sadness the person is laughing. Or it could be the other way round---when people are in a partying mood and laughing, the patient is crying. This is aptly known as inappropriate affect. It is one of the symptoms that suggest a schizophrenic illness that is hard to respond to treatment and suggests a bad outcome. It is one of the so-called negative symptoms of schizophrenia.
3. Especially in the early stages of schizophrenia or when some of the symptoms of schizophrenia come back full-blown---such as frightening or threatening hallucinations--- a schizophrenic patient can during those periods get excited, irritable, sleepless, agitated and move around (motor overactivity) as if in fright. This is understandable---hallucinations can be frightening especially when they start to occur for the first time. Depression can also occur at these stages. Depression can indeed be the very first sign in the early stages leading to the development of schizophrenia. Depression is common in a chronic schizophrenic condition.
Disorders of Movement
It has been postulated that some schizophrenic patients have a disturbance in the motor coordination in the brain. The most dramatic demonstration of this is the so-called catatonic symptoms. A schizophrenic patient with catatonia can maintain one fixed posture for hours on end. He is like a fixed wax sculpture that can be pushed into different positions and left there.
If you lift his right arm upward, bend it at the elbow at a right angle and bend the hand at the wrist also at a right angle so that you form a “U” with right angles and then you push his head backward, he will remain in that position for a long time, until you bend him into other positions. The opposite of this can occur when the patients seems to be excessively active and moving around. Catatonic schizophrenia symptoms are rarer than in the past, but they do occasionally present.
Disorders of Volition Motivations and The Will
Volition is the act of using one’s will in choosing or making a decision. Volition is negatively affected in schizophrenia leading to avolition---an apparent inability or lack of the will to make a decision of what one wants to do, leading to prolonged periods of indecision, and under activity like remaining in bed or sitting, doing nothing. Disorders of volition are regarded as negative symptoms of schizophrenia.
The Social and Occupational Dysfuntions Associated with Schizophrenia
These are not by themselves symptoms of schizophrenia but are a consequence of schizophrenic illness resulting from the disabilities that can follow. A few examples will suffice:
1. Decreased work performance---either in the usual employed or self-employed work
2. If it is a student, there is a gradual deterioration in academic performance after an initial period when the student was doing well prior to the onset of the schizophrenic illness.
3. Overall there is a decline in life expectations so that the original goals of life are not achieved---whether they are social functioning, career expectation, academic goals.
4. The various symptoms of schizophrenia as described above will have a negative impact in the patients relationship with family members, neighbors, workmates, school or college or university mates, etc., leading to a wide spectrum of poor or disrupted or completely abandoned interpersonal relationships.
5. The schizophrenic patient gradually neglects himself in terms of personal hygiene, personal grooming, personal tidiness, and cleanliness. A person who used to be smart will start wearing the same clothes for many days without changing them; will go for several days without taking a shower or bath until the relatives raise concern and even so, he may be very reluctant and request to be left alone.
Issues of Insights
A schizophrenic patient does not know that he is sick. He believes all the symptoms that he is going through are real live experiences. He will therefore resist any attempts to convince him that he needs help and will instead tell off the relatives as the ones who need to see a doctor. He will insist he is feeling well; he has no aches; he is physically fit and has not felt the need to see a doctor.
Different Combinations of Symptoms
Not everybody has all the symptoms of schizophrenia at the same time. Some hear voices but do not have any of the negative symptoms or thought disorder.
Treatment Options for Schizophrenia
These can be divided into two main groups:
1. The use of drugs---pharmacotherapy
2. Psychosocial treatment
Side Effects of the Drugs Used in the Treatment of Schizophrenia
These can be divided into two main categories---those that do not affect the nerves and those that affect the nerves.
Those that Do not Affect the Nerves
1. Dizziness: This is a result of what is referred to postural hypotension. It is common with the older generation drugs. It occurs most frequently during the first few days of treatment, especially if high doses are given. It is characterized by feeling dizzy that can result in a faint or a fall. These can be easily controlled by asking the patient to get up slowly from any lying, squatting or sitting position and, if need be, supported.
2. Dryness that involves several parts of the body, mostly the mouth and the nose. These side effects can be reduced by reducing the dose. In the case of dry mouth, the patient can overcome this by rinsing the mouth frequently or chewing gun that does not contain sugar.
3. Other related side effects include blurred vision, constipation, and difficulty in passing urine.
4. Symptoms related to sex organs
- Breast enlargement
- Secretion of milk by the breast (called galactorrhea---caused by the secretion of an hormone called prolactin)
- Impotence in men
- Irregular or loss of menses in the female
- Reduced sex desire in women
Note: 5. A predisposition to diabetes
6. Skin conditions---allergic skin reaction in a small percentage of patients
7. Pigmentation of the retina is seen in a small percentage of people taking a drug known as thioridazine
8. Weight gain
Side Effects that Affect the Nerves
1. Sedation
2. Increased risk for epileptic attacks
3. Muscular contractions and spasms that can involve the muscles of eyes (resulting in eyes being pulled upward and outward); the neck (causing the neck to be pulled to one side), tongue (causing it to protrude); muscles of the larynx causing stammer.
4. Parkinsonian effects---muscle stiffness; tremor of the hands; stiffness in walking resulting in a shuffling gait; stooped posture of the body and drooling.
5. Akathisia---This is restlessness and agitation causing the patient to pace relentlessly. The symptoms cannot be controlled by the patient’s will.
6. Tardive dyskinesia---this tends to start after prolonged use of antipsychotics and is characterized by uncontrollable irregular movements of the mouth, head, and trunk.
Some Take-Home Messages for Drugs
1. Apart from clozapine, there is little evidence that there are large differences in the effectiveness of any of the typical or atypical antipsychotics. Neither is there any evidence that a particular antipsychotic (typical or atypical) will work better than another.
2. If one does not work change to another.
3. The atypical drugs have less side effects than the typical.
4. Clozapine is currently the choice if any of the above (at least one atypical) do not work. However, apart from its ability to reduce seizures, it has adverse effects on the bone marrow in less than 2% of the people and therefore requires strict monitoring.
5. Antipsychotic drugs should be combined with other psychosocial treatment and for the patient, Cognitive Behavioural Therapy (CBT), in particular.
Electroconvulsive Therapy (ECT)
This is an effective treatment with:
1. No side effects except short-lived forgetfulness.
2. A predictable course–-given over a limited period of time.
It is an option for patients who are not responding adequately to drugs. However, drugs should be continued during and after ECT.
Psychosocial Therapies for the Treatment of Schizophrenia
All of these are meant to increase the social and occupational skills of the patient so that he retains and/or improves his interpersonal relations with the family/friends while at the same time retaining his occupational skills. All of the psychosocial support system must be socioculturally and economically contextualized. Most developing countries do not have the privilege of public supported day centres or subsidized houses that the schizophrenic patients can live in on their own away from hospital or their homes. Neither is there an easy availability of jobs even for those who are physically or mentally well. Therefore, the responsibility of the care of the schizophrenic patient falls squarely on the family’s shoulders.
The family is particularly relevant since they are the caregivers. Like the patient they need to be educated on the nature of the condition and its symptoms and how they present; the drugs, the side effects, why it is important for the patient to take the drugs regularly. They should be given the opportunity to ask questions even on issues of genetics and any blame within the family. The family would need to be educated on how to relate with and express emotions to the patient.
Group therapy for the patients, even when they at the hospital, will help them to articulate the issues that concern them and also learn coping skills and mistakes to avoid from each other. Individualized psychological support is a viable option. CBT has been shown to work. In this you help the patient to understand his illness; how to focus and build on the positive aspects of his life (Details of CBT are to be found in a different chapter).
Self-Help for Schizophrenic Symptoms
1. Learn all you can about your condition–-the early signs and symptoms, so that you can raise your own red flag early and do something about. Learn about the drugs used and their side effects, how and why they should be taken and for how long. You can get this information by talking to a health professional or by reading. This book is meant to educate you and your relatives.
2. Learn about your rights---that you are entitled to be treated like any other patient and that if other people stigmatize you, it is their problem not yours. If you have the opportunity, remind them they are wrong. (Read also the relevant chapter on this book about your rights)
3. Study carefully the things that unduly cause you stress and avoid them if you can and if you cannot discuss them with a caring person or the doctor. Read as much as you can about stress and stress management. (See relevant sections in this book)
4. Do not stay idle---keep yourself busy.
5. Take good care of your health through physical exercises such as walking, working in the garden, helping in the house, etc., eating a balanced diet with fresh vegetables and fruits; avoid drugs.
6. Though it is difficult to ignore symptoms such as voices, keep on reminding yourself that they have no power over you and cannot harm you.