SCHIZOPHRENIA
SCHIZOPHRENIA
The word ‘Schizophrenia’ was coined in 1908 by the Swiss psychiatrist Eugen Bleuler. It is derived from the Greek words skhizo (split) and phren (mind).
Schizophrenia is a psychotic condition characterized by a disturbance in thinking, emotions, volitions and faculties in the presence of clear consciousness, which usually leads to social withdrawal.
Prevalence
The lifetime prevalence of schizophrenia is estimated to be around 0.3% to 0.7%.
Rates vary with race/ethnicity, countries, and geographic regions, and are influenced by immigration.
Sex differences also appear across studies:
Populations that emphasize negative symptoms and longer illness duration show a higher rate in males, linked to less favorable outcomes.
Groups that include more mood symptoms and brief psychotic episodes show similar risk in both sexes, often with better outcomes.
Development and Course
The core psychotic symptoms typically appear from the late teens through the mid-30s, and onset before adolescence is uncommon.
The first psychotic episode often appears in the early to mid-20s for males and in the late 20s for females.
Onset can be sudden, but most individuals show a slow, gradual development of symptoms and functional decline.
About half of affected individuals complain of depressive symptoms.
Earlier onset has traditionally been viewed as predicting a worse outcome, though the link is inconsistent.
Early signs may include: social withdrawal, low motivation, academic/work problems, and prominent negative symptoms.
Cognitive impairment is common and often precedes psychosis, remaining even when other symptoms lessen.
Course and outcome are unpredictable, though about 20% have a favorable course, and a small number recover fully.
Most individuals need continuous medical or social support, with patterns of relapses and remissions or steady deterioration.
Psychotic symptoms usually decline with age, possibly due to age-related reduction in dopamine activity.
Negative symptoms are more persistent and more strongly tied to long-term prognosis.
Cognitive deficits tend not to improve over the course of the illness.
In childhood, the essential features are similar to those in adults, but diagnosis is more challenging.
Children often show less complex delusions, and visual hallucinations are more frequent and must be differentiated from normal fantasy.
Disorganized speech and disorganized behavior appear in multiple childhood disorders, not only schizophrenia.
Children later diagnosed often had nonspecific emotional/behavioral problems, language and motor delays, and intellectual difficulties.
Late-onset cases (after age 40) occur more often in females, many of whom have been married.
These cases typically show more psychotic symptoms with generally retained affect and functioning.
Etiology
Many authorities suggest that multiple factors must cause schizophrenia, because no single theory satisfactorily explains the disorder.
A.Biological Theories
Biologic explanations include biochemical, neurostructural, genetic, perinatal risk factors and other theories.
1.Biochemical Theories
Dopamine hypothesis: This theory suggests that an excess of dopamine-dependent neuronal activity in the brain may be the cause of schizophrenia. Most of the antipsychotic drugs have high affinity for dopamine receptors. Other neurotransmitters such as norepinephrine, serotonin, acetylcholine and gamma-aminobutyric acid (GABA), and neuroregulators such as prostaglandins and endorphins, have been implicated in predisposing to schizophrenia. These include abnormalities in the neurotransmitters norepinephrine, serotonin, acetylcholine and gamma-aminobutyric acid (GABA), and neuroregulators such as prostaglandins and endorphins.
2.Neurostructural Theories
Research suggests that the prefrontal cortex and the limbic cortex may never fully develop in the brains of persons with schizophrenia. Computed Tomography and Magnetic Resonance Imaging (MRI) studies of brain structure show:
* Decreased brain volume
* Larger lateral and third ventricles
* Atrophy in the frontal lobe, cerebellum and limbic structures
* Increased size of sulci on the surface of the brain.
3.Genetic Theories
The disease is more common among people born of consanguineous marriages. Studies show that relatives of schizophrenics have a much higher probability of developing the disease than the general population
Genetic Risk of schizophrenia
- Identical twin affected 50%
- Fraternal twin affected 15%
- Brother or sister affected 10%
- One parent affected 15%
- Both parents affected 35%
- Second degree relative affective 2–3%
- General population 1% (No affected relative)
Perinatal Risk Factors
Multiple non-genetic factors influence the development of schizophrenia.
Prenatal and perinatal risk factors for schizophrenia
- Maternal influenza
- Birth during late winter or early spring
- Complications of pregnancy particularly during labor and delivery
B.Psychodynamic Theories
These theories focus on individual’s responses to life events.
1.Developmental Theories
According to Freud, there is regression to the oral stage of psychosexual development, with the use of defense mechanisms of denial, projection and reaction formation. The individuals have poor ego boundaries, fragile ego, inadequate ego development, superego dominance, regressed id behavior, love-hate (ambivalent) relationships and arrested psychosexual development.
2.Family Theories
Family relationships act as major influence in the development of illness.
Mother-child relationship: Early theories characterized the mothers of schizophrenics as cold, over-protective, and domineering. They have been termed as “schizophrenogenic mothers”, who prevent the child from maturing and achieving independence.
Dysfunctional family system: Hostility between parents can lead to a schizophrenic daughter (marital skew and schism).
Double-blind communication (Bateson et al., 1956): Parents convey two or more conflicting and incompatible messages at the same time.
Vulnerability–Stress Model
This model recognizes that both biologic and psychodynamic predispositions to schizophrenia, when coupled with stressful life events, can precipitate a schizophrenic process. According to this model, people with a predisposition to schizophrenia may avoid serious mental disorders if they are protected from the stresses of life. Individual with a similar vulnerability may succumb to schizophrenia if exposed to stressors.
Social Factors
Studies have shown that schizophrenia is more prevalent in areas of high social mobility and disorganization, especially among members of very low social classes. Stressful life events also can precipitate the disease in predisposed individuals.
Positive And Negative Symptoms Of Schizophrenia
Positive
- Hallucinations
- Delusions
- Agitation
- Disorganized behavior
- Suspiciousness
- Hostility
- Bizarre behavior
- Formal thought disorder
Negative
- Affective flattening or blunting
- Attention impairment
- Avolition (inability to experience pleasure)
- Anhedonia
- Alogia (lack of speech output)
- Apathetic social withdrawal
- Poor rapport
- Lack of spontaneity
- Emotional withdrawal
Prognostic Factors In Schizophrenia
Good Prognostic Factors
-
- Later age of onset
- Acute onset
- Good premorbid personality
- Precipitating stressor present
- Family history of affective disorders
- Good treatment compliance
- Paranoia/high intelligence
- Good social support and relationships
- Mood disorder symptoms
- Outpatient treatment
Poor Prognostic Factors
-
- Earlier age of onset
- Insidious onset
- No precipitating factor
- Frequent relapses
- Family history of schizophrenia
- Poor treatment compliance
- Prominent negative symptoms
- Single, divorced or widowed
- Substance dependence
- Institutionalization
Treatment
Pharmacotherapy
The goal of schizophrenia treatment is to provide effective antipsychotics, reduce symptoms, prevent relapse and improve quality of life. Antipsychotics are broadly used to treat schizophrenia.
Psychological Therapies
Group therapy: The social interaction, sense of cohesiveness, identification, and reality testing achieved within the group setting have proven to be highly therapeutic for these individuals.
Behavior therapy: Behavior therapy is useful in reducing the frequency of bizarre, disturbing and deviant behavior, and increasing appropriate behaviors.
Social skills training: Social skills training addresses behaviors such as poor eye contact, odd facial expressions and lack of spontaneity in social situations through the use of videotapes, role playing and homework assignments.
Cognitive therapy: Used to improve cognitive distortions like reducing distractibility and correcting judgment.
Family therapy: Family therapy typically consists of a brief program of family education about schizophrenia. It has been found that relapse rates of schizophrenia are higher in families with high expressed emotions (EE), where significant others make critical comments, express hostility or show emotional over-involvement. The significant others are, therefore, taught to decrease expectations and family tensions, apart from being given social skills training to enhance communication and problem solving.
Psychosocial Rehabilitation
This includes activity therapy to develop the work habit, training in a new vocation or retraining in a previous skill, vocational guidance and independent job placement.
Electroconvulsive Therapy (ECT)
Indications: ECT in schizophrenia include:
* Uncontrolled catatonic excitement
* Extreme negativism
* Severe (profound) depression
* Schizophrenia refractory to all other forms of treatment
Usually 8–12 ECTs are needed.
When Do People With Schizophrenia Need Medication and Hospitalization?
People with schizophrenia need to be on regular antipsychotic medications to control symptoms like delusions, hallucinations, and disorganized thinking, and to prevent relapse. Medication is usually long-term or lifelong because stopping it often leads to a quick return of symptoms. Hospitalization becomes necessary when the person’s safety or well-being is at risk—such as when they experience severe psychosis, suicidal or violent behavior, catatonia, extreme agitation, or when they stop taking medication and are unable to care for themselves. In such situations, inpatient care provides close monitoring, stabilization, and structured treatment until the person is safe and stable enough to continue care as an outpatient.