The theme of this year's World Mental Health Day -
which takes place on 10 October is’ “shines a light on schizophrenia”.
Schizophrenia
is a disorder of brain function, affecting thoughts, feeling and acts of an
individual. Symptoms develop either
progressively or appear abruptly and vary from one patient to another. The
disease evolves in cycles of remission and relapses. Over time, slow decline in
mental function and social relationships occurs. This leads to a marked
personality change, social isolation, occupational disability, cognitive
impairment and poor health. An estimated
of around 1% population suffers from schizophrenia mostly in the age group of
15-35 years. According to a World Health Organization estimate, schizophrenia
was the 5th leading worldwide cause of global disease burden in the
last decade with years lived with disability (YLD) among males (2.8%) and in
females (2.6%).
Many factors are considered as possible cause of
schizophrenia which includes, genes, environment, different brain chemistry and
structure etc. Figure 1 summarizes the possible etiology of schizophrenia.
Figure
1. Etiology of schizophrenia
Source: Zubin
and Spring, 1977
Schizophrenia
has emerged as a financial burden on society because of the potential for
institutionalization and chronic use of treatments. A study in United States of America on economical burden per
patient towards criminal justice and psychiatric hospitalization cost has put
the cumulative three-year costs to the state government at $21,146,000 for
criminal justice and $25,616,000 for hospitalization costs of patients
(respectively $3,984 per patient and $4,827 per patient). A relative 20%
increase in the proportion of patients receiving antipsychotic treatment
following release from incarceration has decreased total cumulative costs over
three years by $1,871,100 ($353 per patient).
Schizophrenia
has associated humanistic burden which concerns patients, but also caregivers,
relatives, neighbors and other individuals in a patient’s daily life. In
most of the developing countries, individuals with schizophrenia live with their families; family burden is an important component of the
impact of the illness on the community that should be included in measures of
the relative social and economic importance of the condition. Even after
symptoms subside, patient’s disability is independently associated with family
burden. It is important to target both symptoms and disability in treatment
strategies for this severe, often lifelong, condition.
Early signs and
symptoms
In many persons, schizophrenia appears suddenly and
without warning, but in most of the cases it comes down slowly with warning
signs and gradual decline in functioning. The most common early warning signs
of schizophrenia includes.
- Social withdrawal
- Hostility
and suspiciousness
- Deterioration
of personal hygiene
- Flat,
expressionless gaze
- Inability
to cry or express joy; Inappropriate laughter or crying
- Depression
- Oversleeping
or insomnia
- Odd or
irrational statements, strange use of words
- Forgetful;
unable to concentrate
- Extreme
reaction to criticism
Common Symptoms
There are two categories of symptoms
- Positive
symptoms – are disturbances added to the personality of an individual and
usually respond well to medication that may include delusions, disordered
thought and speech, tactile auditory, visual, olfactory and gustatory
hallucinations.
- Negative
symptoms- are the capabilities that are lost from the individual’s
personality and do not respond to medication, includes, social withdrawal,
extreme apathy, lack of drive or motivation and emotional
unresponsiveness.
Diagnosis
Diagnosis of schizophrenia is based on a full
psychiatric evaluation, medical history, physical examination and laboratory
tests.
Psychiatric
evaluation: The doctor or psychiatrist asks a
series of questions which can cover family life psychiatric history and family
history of mental health problems.
Medical history
and exam: Doctor may ask and evaluate personal and family
health histoy. A complete physical examination is required for medical issues
that could be causing or contributing to the problem.
The following criteria are
used for confirmation of schizophrenia:
- The
presence of two or more of the following symptoms for at least 30 days
may be a case of schizophrenia-
1. Hallucinations
2. Delusions
3. Disorganized
speech
4. Disorganized
or catatonic behavior
5. Negative
symptoms (emotional flatness, apathy, lack of speech)
- Significant
problems in functioning at work or school, relating to other people
and taking care of oneself.
- Continuous
signs of schizophrenia for at least 6 months, with active symptoms
(hallucinations, delusions, etc.) for at least 1 month.
- No
other mental health disorder, medical issue, or substance abuse
problem is causing the symptoms.
Differential diagnosis of
schizophrenia covers, psychotic disorders such as schizoaffective disorder,
schizophreniform disorder and brief psychotic disorder resembles schizophrenia.
Additionally, some substance abuse like alcohol, heroin, amphetamines and
cocaines may also triggers psychotic symptoms resembling schizophrenia.
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Laboratory Tests: While
there are no specific laboratory tests that can diagnose schizophrenia, simple
blood and urine tests can rule out other medical causes of symptoms.
Brain-imaging studies, such as MRI or a CT scan, may also be prescribed in
order to look for brain abnormalities associated with schizophrenia.
Types of Schizophrenia
Schizophrenia is categorized into different types
based on different symptoms in an indivisual
- Paranoid schizophrenia – in this
type a person feels extremely suspicious, persecuted, or grandiose, or
experiences a combination of these emotions.
- Disorganized schizophrenia –
individual often shows incoherent speech and thought, but may not have
delusions.
- Catatonic Schizophrenia –
catatonia is now a days not related to schizophrenia, but patients in this
category is withdrawn, mute, negative and often assumes very unusual body
positions.
- Residual schizophrenia – in this
condition a person may no longer experience delusions or hallucinations,
but has no motivation or interest in life.
- Schizoaffective disorder- a person
has symptoms of both schizophrenia and a major mood disorder such as
depression.
- Post-schizophrenic depression – a phase
of depression arising after a schizophrenic illness where some low level
schizophrenic symptoms persists.
- Simple schizophrenia – In this
type a progressive development of prominent negative symptoms occurs in
patients with no history of psychotic episodes.
Red
Flag Signs
· Overall
mortality rate due to schizophrenia has been estimated two to three times
high as for general people.
· Most
dangerous aspect associated with schizophrenia is the violent behavior of
the patient.
· In
this condition the patient can grievously harm him/herself and also any person
in surrounding including family members and caregivers.
· Suicidal
behavior in schizophrenic patients has remained the biggest risk.
· Around
4-13% of patients with schizophrenia attempt suicide which is many times
higher than normal population.
· Suicide
is not the only cause of higher mortality in schizophrenic patients but
obesity, cardiovascular diseases also play a significant role.
· Reduced
activity and movement the patient gains weight which also puts him at risk
of developing metabolic disease.
· Criminal
victimization has been reported to be most frequently associated with
alcohol and/or illicit drug use/abuse, homelessness and engagement in
criminal activity.
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Management
It is still hard to pin point on the exact cause of
schizophrenia, making hard the complete treatment of the disease. Till date no
cure is available for schizophrenia. In the current time management of
schizophrenia includes treatments which focus on eliminating symptoms of the
disease. The treatment methodologies include antipsychotic medications and
various psychosocial treatments.
Antipsychotic
medications
These medicines are available for more half of the
century. The older types are called conventional or typical antipsychotics. These
medicines can reduce the positive symptoms of schizophrenia in about 7-14 days.
Antipsychotics have no significant effect on reducing the negative symptoms and
cognitive dysfunction. Patients using antipsychotics continuously have a
decreased risk of relapse. The benefits of antipsychotic drugs become
inconsistent beyond three years of their continuous use.
Some of the commonly used effective antipsychotic
drugs are -
- Clozapine
- Amisulpride
- Olanzapine
- Rispoeridone
- Quetiapine
- Ziprasidone
- Aripiprazole
- Paliperidone
These drugs give good response in 40-50% patients
and in 30-40% patients it gives partial response, making these drugs a
frontline treatment option in newly diagnosed cases. Resistance to these drugs
can be observed after 6 weeks of treatment, either alone or in combination with
other psychotic drugs. The side effects associated with these drugs includes
weight gain, diabetes and metabolic disorders. These drugs are contraindicated
in pregnancy and women of child bearing age.
Psychosocial
therapy
The second line of treatment most commonly used for
schizophrenia is psychosocial therapy. These treatments are most effective for
patients who are already stabilized on antipsychotic medication. The
psychosocial treatment helps these patients to deal with everyday challenges
and hardships associated with the ailment such as difficulty in communication,
self care, work and forming and keeping relationships. Patients on psychosocial
therapy are regular in taking their oral medications making them less
vulnerable to relapse and hospitalization for violent episode. The therapist
can provide education about the disorder, common symptoms or problems patients
may experience and the importance of staying on medication.
The psychosocial therapy may also help the patient
in –
-
Illness management skills by providing knowledge
-
Integrated treatment for co-occurring
substance abuse, if any.
-
Rehabilitation of the patients including
boosting the confidence and vocational training
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Family education i.e. training to the
family members or care givers to efficiently manage and care of the affected person post-hospital discharge
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Cognitive behavioral therapy is a type
of psychotherapy which focuses on thinking and behavior. It helps to tackle
with those symptoms which are hard to eradicate using drugs.
Ultimately the support of family and peers is very
important to build up confidence in patients after oral medications therapy and
reduction of psychotic symptoms. There help and support can make the
rehabilitation easy and reduce the cases of relapse and chances of further
hospitalization.
Prevention of
schizophrenia
Preventing schizophrenia before it appears is still
under intensive early stages of research. There are some positive signs
observed which can provide clue on preventing schizophrenia ad lowering the
risk. Currently two approaches are under investigation for prevention of
schizophrenia.
- Preventive
measures taken prior to any measurable signs and symptoms of early phase
(prodormal phase) of schizophrenia .
- Preventive
measures taken during the prodormal period of schizophrenia, where patient
starts showing early signs of the condition.
Genetic factors are thought to be associated with
development of schizophrenia. Preventing close marriages for prevention of
expression of defective genes may play a significant role in people with family
history of schizophrenia. Environmental factors have been identified as culprit
of increasing the risk of schizophrenia. Environmental factors may include
everything from the nutritional environment or viruses to social environment
growing up to teen drug use or stress. Curbing these factors may significantly
decrease the risk of schizophrenia.
Methods for
awareness
Awareness about the disease is the key to early
diagnosis and proper management of the patients. A delay in identification of
symptoms and proper care risks the aggravation of the condition. High risk
group people such as person with family history of schizophrenia, using
drugs/substance of abuse, stressed workers and smokers may be made aware of the
risk factors associated with their behavior.
Families and peers of affected person may also be made
aware and asked to follow the coping guidelines to properly take care of the
patient. Some of points of coping guidelines are as follows:
- A daily routine
for the patient should be established
- Educate and try to
help the patient to stay on medication
- Discuss about
problems or fears the patient may have
- Understand about
the emotionally and physically exhaustive care of patient
- Keep
communications simple and brief when communicating with patient.
- Be patient and
calm
- Ask for help if needed;
join a support group.
Showing love and support for the patient is the key
for managing schizophrenia and awareness along with proper therapy may improve
the life and reduce the risks of deterioration of the patient’s condition.
References:
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