http://www3.ns.sympatico.ca/ssns/ E-Mail: ssns@as.sympatico.ca
Edited version of content presented on The Schizophrenia Society of Nova Scotia Website
Edited by G Dawe 31st December 2001.
I find this information from The
Schizophrenia Society of Nova Scotia useful as it gives an account of a number
of current issues surrounding the illness schizophrenia.
Schizophrenia is a complex disorder. It
develops into a full-blown illness in late adolescence or early adulthood. It
is characterized by delusions, hallucinations, disturbances in thinking and
communication, and withdrawal from social activity. Schizophrenia is a serious
but treatable disorder that can effect a person's personal ability. A short
explanation of how the brain works may help to promote understanding about
schizophrenia.
There are nerve cells in the brain and
central nervous system. Each nerve cell has branches that transmit and receive
messages from other nerve cells. The nerve endings release chemicals, called
neurotransmitters that carry messages from the end of one nerve branch to the
cell body of another. In people effected by schizophrenia, something goes wrong
in this process of cellular communication. Comparing the brain to a telephone
switchboard may be helpful in understanding schizophrenia.
Schizophrenia may develop gradually or it
may have a very sudden onset. It commonly appears between the ages of sixteen
and thirty. It is rare for a first episode of the disorder to appear after the
age of forty. Schizophrenia is found worldwide, it effects normal and
intelligent people and effects people in all walks of life. Schizophrenia
occurs in men and women, effecting one percent of the general population.
Sometimes schizophrenia-like symptoms may
occur with other diseases such as Huntington's disease, phenylketonuria,
Wilson's disease, epilepsy, tumour, encephalitis,
meningitis, multiple sclerosis, and
numerous other diseases. Schizophrenia is diagnosed when these other conditions
are excluded as the source of the psychotic symptoms.
The precise cause of schizophrenia
remains unknown. Changes in key brain functions, such as thinking, emotions and
behaviour, indicate that the brain is a major site of the biological basis of
schizophrenia. Neurotransmitter (the substances through which cells
communicate) disturbance may be involved as either a cause or as an effect.
There may be changes in dopamine, serotonin, or other neurotransmitters, the
limbic system (an area of the brain involved with emotion), the thalamus (which
coordinates outgoing messages), or several other possible brain changes. Do the
changes that eventually lead to schizophrenia begin to occur early in the
person’s brain development?
Is it true to say that genes control the
activity of neurotransmitters or that genes are involved in causing
schizophrenia? This idea is derived from family, twin and other studies.
Schizophrenia occurs in 1% of the general population, but the risk is increased
if a relative is affected. There is a 10-15% chance of developing the illness when
a sibling or one parent has schizophrenia; when both parents have schizophrenia
the risk raises to approximately 40-50%. Nieces, nephews or grandchildren of
someone with schizophrenia have about a 3% chance of developing the disorder.
The chance that an identical twin will be affected with schizophrenia if their
co-twin has this illness is about 50%.
Chromosomes and genes may be identified
in the future that will help in diagnosis and genetic counselling and
eventually in developing new treatment for schizophrenia.
In addition to genes, other factors that
may disrupt normal functioning of various neurotransmitters are stress, viral
or other infections, drug abuse, and nutrition.
The role of stress in schizophrenia is
unclear. Stress does not cause the illness, but emotional or physical stress
can trigger or worsen the symptoms when the illness is already present.
Drugs themselves do not cause
schizophrenia. However, street drugs and alcohol can make psychotic symptoms
worse if a person already has schizophrenia. Some drugs can temporarily create
schizophrenia like symptoms in normal persons.
While scientists recognize that proper
nutrition is essential for the well being of a person, they do not agree that a
lack of certain vitamins causes schizophrenia. Cures with megavitamin therapy
are not proven and are often very expensive. Some people do improve while
taking vitamins; however, this may be due to the antipsychotic medication they
are taking at the same time, the therapeutic effect of a structured diet,
vitamin and medication regime, or they may be part of the 30% who recover no
matter what treatment is used.
To make the diagnosis and treatment of
schizophrenia easier and more effective, psychiatrists have attempted to
classify schizophrenia into several types. Please refer to classifications of
schizophrenia reported in ICD 10 & DSM 4R documents for more detail. These
classifications are based on experience and research with observable behaviour,
symptoms and feelings described by patients and observations made by family
members, nurses, family doctors, and psychiatrists.
This type of schizophrenia, commonly
referred to as the hebephrenic type, has the following diagnostic criteria:
This type is characterized by extreme
suspiciousness, delusions and/or hallucinations with persecution, or less
commonly, an exaggerated sense of self-importance. Other features exhibited for
no apparent reason may be anxiety, anger, quickness to quarrel, jealousy, and
occasionally violence.
Diagnostic criteria for the catatonic
type of schizophrenia includes:
Sometimes the major psychotic symptoms
cannot be classified into any category listed, or may match the criteria for
more than one type of schizophrenia.
This category is used when there is at
least one recognizable episode of schizophrenia, but no ongoing obvious
psychotic symptoms, through less clear signs of the illness continue such as
social withdrawal, eccentric behaviour, inappropriate emotions and thinking,
etc.
Psychiatrists talk about symptom
clusters: positive symptom clusters, negative symptom clusters, disorganized
behaviour clusters, mood symptom clusters and cognitive symptom clusters.
People with schizophrenia may be treated
according to the clusters of symptoms they have. In terms of medication, people
with schizophrenia may be prescribed antipsychotic medications that are
targeted to different symptom cluster psychosis domains.
The signs and symptoms may vary with each
individual. The person with schizophrenia will deteriorate in areas such as:
·
Work or academic achievements
·
Personal care and hygiene
·
Interaction with others
Personality changes are a key to
recognizing schizophrenia. At first, the changes may be subtle, minor and go
unnoticed. As they worsen they become obvious to family members, friends and
co-workers. There is a loss of feeling or emotions and a lack of interest and
motivation. A normally outgoing person may become withdrawn, quiet, moody,
suspicious, and/or even paranoid.
One of the most profound signs relates to
the person's ability to think clearly and logically. Thoughts may be slow in
forming or seem confused or the person may have difficulty reaching easy
conclusions. Thinking may be coloured by delusions and false beliefs that
resist logical explanations. One person may express ideas of persecution,
convinced that they are being spied on or plotted against. Others may
experience delusions, believing they are capable of anything and may report
feeling invulnerable to danger. Others may feel a drive to right all the wrongs
of the world.
Perceptual changes turn the world of the
person topsy-turvy. The nerves carrying sensory messages to the brain from the
eyes, ears, nose, skin and taste buds may activate and the person may see,
hear, smell, and feel sensations which are not real. These are called
hallucinations.
It is easy to understand why a person who
experiences these changes may seek to keep them secret; deny that anything is
happening or avoid people and situations where they may be discovered. The
feedback they receive when they express hallucinations or delusions may be
disbelief. The person may then feel misunderstood and rejected and cease to
share their thoughts as a result.
Understanding the terminology used by
doctors can help to assist understanding schizophrenia. The symptoms of
schizophrenia are classified into two categories: positive symptoms and
negative symptoms.
Hallucinations are thought to be a result
of over-sharpening of the senses and of the brain's inability to interpret and
respond appropriately to incoming messages. A person with schizophrenia may
hear voices or experience unusual sensations on or in their bodies. Auditory
hallucinations are the most common form of hallucination reported and these
involve hearing voices that are perceived to be inside or outside of the
person's body. Sometimes the voices may be complimentary or reassuring.
Sometimes they may be threatening, punitive, frightening and they may command
the individual to do things that may be harmful to themselves or to others.
Delusions are false and fixed beliefs
that are held only by the person suffering from the disorder. The person
despite obvious evidence to the contrary may maintain delusions. People
effected by schizophrenia who suffer from persecution delusions are termed
paranoid. They may believe that they are being watched, spied upon or plotted
against. A common delusion may be that one's thoughts are being broadcast or
that other people are controlling the person's thoughts. Delusions are
resistant to reason.
Thought disorder refers to problems in
the way that a person with schizophrenia processes and organizes thoughts. For
example, the person may be unable to connect thoughts into logical sequences.
Racing thoughts come and go so rapidly that it is not possible to catch them.
Because thinking is disorganized and fragmented, the person's speech may be
incoherent and illogical. Thought disorder may be accompanied by inappropriate
emotional responses: words and mood may not appear connected to each other.
Altered sense of self is reported as
describing a blurring of the person's feeling as to what they are. It may
present as a sensation of being bodiless or non-existent as a person. The
person may not be able to tell where their body stops and the rest of the world
begins. Or they may feel as if the body is separated from the person.
Lack of motivation or apathy is a lack of
energy or interest in life that may be confused with laziness. Because the
person has very little energy, they may not be able to do much more than sleep
and pick at meals. The person with schizophrenia may be experiencing life
without any real interest in it.
Blunted feelings or blunted affect refers
to a flattening of the emotions. Because facial expressions and hand gestures
may be limited or nonexistent, the person with schizophrenia may be unable to
feel or show any emotion at all. This does not mean that the person does not
feel emotions and is not receptive to kindness and consideration. They may be
feeling very emotional but cannot express it outwardly. Blunted affect may
become a stronger symptom as the disease progresses.
Depression may involve feelings of
helplessness and hopelessness and may stem in part from realizing that
schizophrenia has changed one's life; that the feeling experienced in the
psychotic state is an illusion and that the future looks bleak. The person may
believe that they have behaved badly, destroyed relationships and are
unlovable.
Feelings may be very painful and may lead
to talk of or attempts at self-harm including suicide. Social withdrawal may
occur as a result of depression; a feeling of relative safety in being alone;
being caught up in one's own feelings, and/or fearing that one cannot manage
the company of others. People with schizophrenia frequently lack an interest in
socializing or at least the ability to demonstrate/express this interest.
The person should leave the hospital with
a treatment plan that would both minimize symptoms and maximize their quality
of life. The treatment plan may include taking antipsychotic medication for an
extended period of time. Beyond this key element, the treatment plan for the
stabilization phase should reflect the person's needs as well as their wishes
or preferences. Hospitals and mental health services may offer individual or
group psychotherapy. Multidisciplinary staff may give help to the person with claiming
disability benefits and housing support programs. Family education programs,
that may be separate from activity that involves the patient, are a way to give
information to a family about how to support themselves and their relative who
has schizophrenia.
During the stabilization phase, the
person may still be fragile, both neurochemically and psychologically. Symptoms
of moderate severity may still be present, medication may can take weeks
or months to reduce symptoms. As such,
the best treatment activities may be more basic and gentle than they need to be
in the later, stable phase. It may be better to have more structured and less
complex treatment activities.
Sometimes outpatient treatment services
are grouped together into a Day Program where patients may make a commitment to
a block of group activities for several days per week. Other services allow
patients to pick and choose from groups so that their activities more closely
reflect their needs. Individual counselling and psychotherapy may or may not be
part of these Day Programs.
Information about outpatient treatment
services should be available as a list of outpatient services from local
hospitals and health care clinics.
There are many kinds of antipsychotic
medicines in common use. Each drug has a generic or chemical name and a brand
name used by the pharmaceutical companies that manufacture it.
Medication is the bedrock of treatment
for schizophrenia. Once the most acute stage of a psychotic episode has passed,
patients should take their medicine indefinitely. This is because the
vulnerability to psychosis doesn't go away, even though some or all of the
symptoms do. Without regular medication, the chance of a relapse in 2 years is
80-90%. By contrast, the 2-year relapse rate is cut in half if a person with
schizophrenia does nothing except take antipsychotic medication as prescribed.
Adding other treatment measures even further reduces relapse rates. Thus,
medication has a preventative role in the long run as well as a symptom relief
role in the short run.
The first generation medicines were
introduced between 1955 and 1980. They were discovered by chance to be
effective against hallucinations and delusions and only after research was it
known that they blocked dopamine receptors. They were then used to treat the
positive symptoms of schizophrenia. The second-generation medicines have been
available since 1990. They work equally well on positive symptoms and have a
documented advantage in relieving negative symptoms.
The second generation antipsychotic,
clozapine, was developed to act on a variety of neurotransmitter receptors.
Risperidone was developed specifically to block serotonin and dopamine
receptors equally. Olanzaphine and quetiapine were developed to act like
clozapine. Because they are less potent at the dopamine receptor, they tend to
have fewer side effects with the blockage of dopamine, e.g., tremor, stiff
muscles, and agitation. Unfortunately, they have their own undesirable effects,
which can lead to a tendency to gain weight. This can be more of a health
hazard than stiffness and tremors.
Antipsychotic Medications
|
|
|
Chemical Name |
Pharmaceutical |
|
Chlorpromazine
Hydrochloride |
Largactil |
|
Flupenthixol |
Depixol |
|
Fluphenazine
Hydrochloride |
Modecate |
|
Zuclopenthixol
Dihydrochloride |
Clopixol |
|
Loxapine |
Loxapac |
|
Haloperidol |
Serenace |
|
Pimozide |
Orap |
|
Sulpiride |
Dolmatil |
|
Trifluoperazine |
Stelazine |
|
Amisulpride |
Solian |
|
Quetiapine |
Seroquel |
|
Clozapine |
Clozaril |
|
Olanzapine |
Zyprexa |
|
Risperidone |
Risperdal |
Less research is conducted into
schizophrenia than on any other major disease. Given both the human and the
financial burden that this illness imposes, this deficit must be remedied.
Most research conducted until the end of
the Second World War was biological, after which there was an interlude of 10
to 15 years when psychiatry based its attempts to understand and to treat mental
illness on the study of human behaviour. This approach led to the development
of psychoanalytic techniques, this treatment is not effective for patients with
schizophrenia.
Modern research into the biological
causes of the disorder began with the introduction of the neuroleptic drugs in
the 1950's. This brought about a change in the direction of research on
schizophrenia and its possible causes, from the behavioural to the
neurochemical. It is accepted that the symptoms of the disorder arise from a failure
of the chemical processes in the brain to function properly. Today, the primary
thrust in research on schizophrenia is to discover the reasons for this
failure.
Research expenditures on schizophrenia
still lag behind those on other serious illnesses. Research interest in this disorder
has increased greatly throughout the world in recent years. Scientists perceive
a much wider range of opportunity in the search for answers.
http://www3.ns.sympatico.ca/ssns/ E-Mail: ssns@as.sympatico.ca
Edited
version of content presented on The Schizophrenia Society of Nova Scotia Website