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Schizophrenia

Schizophrenia

Schizophrenia is a chronic, severe, and disabling mental illness. It affects men and women with equal frequency.

 

People suffering from schizophrenia may have the following symptoms: 

 

  • Delusions, false personal beliefs held with conviction in spite of reason or evidence to the contrary, not explained bythat person's cultural context.
  • Hallucinations, perceptions (can be sound, sight, touch, smell, or taste) that occur in the absence of an actual external stimulus (auditory hallucinations, those of voice or other sounds, are the most common type of hallucinations in schizophrenia).
  • Disorganized thoughts and behaviors.
  • Disorganized speech.
  • Catatonic behavior, in which the affected person's body may be rigid and the person may be unresponsive.

 

The term schizophrenia is Greek in origin, and in the Greek meant"split mind." This is not an accurate medical term. In Western culture, some peoplehave cometo believe that schizophrenia refers to a split-personality disorder. These aretwo very different disorders, and people with schizophrenia do not have separate personalities.

 

Schizophrenia and other mental health disorders have fairly strict criteria fordiagnosis. Time of onset as well as length and characteristics of symptoms are all factors. The active symptoms of schizophrenia must be present at least 6 months, or only 1 month if treated.

 

Who is affected?

 

   • Estimates of how many people are diagnosed with this disorder vary.The illness affects about 1% of the population. More than 2 million Americans suffer from schizophrenia at any given time, and 100,000-200,000 peopleare newly diagnosed every year. Fifty percent of people in hospital psychiatric care have schizophrenia.

   •  Schizophrenia is usually diagnosed in peopleaged 17-35 years. The illness appears earlier in men (in the late teens or early twenties) than in women (who are affected in the twenties to early thirties). Many of them are disabled. They may not be able to hold down jobs or even perform tasks as simple as conversations. Some may be so incapacitated that they are unable to do activities most people take for granted, such as showering or preparinga meal. Many are homeless. Some recover enough to live a life relatively free from assistance.

Symptoms

Usually with schizophrenia, the person's inner world and behavior change notably.

 

Behavior changes might include the following: 

 

  • Social withdrawal.
  • Depersonalization (intense anxiety and a feeling of being unreal).
  • Loss of appetite.
  • Loss of hygiene.
  • Delusions.
  • Hallucinations (eg,hearing things not actually present).
  • The sense of being controlled by outside forces.

 

A person with schizophrenia may not have any outward appearance of being ill. In other cases, the illness may be more apparent, causing bizarre behaviors. For example, a person with schizophrenia may wear aluminum foil in the belief that it will stop one's thoughts from being broadcasted and protect against malicious waves entering the brain.

 

People with schizophrenia vary widely in their behavior as they struggle with an illness beyond their control. In active stages, those affected may ramble in illogical sentences or react with uncontrolled anger or violence to a perceived threat.

 

People with schizophrenia may also experiencerelatively passive phases of the illnessin which they seem to lack personality, movement,and emotion (also called a flat affect). People with schizophrenia may alternate in these extremes. Their behavior may or may not be predictable.

 

In order to better understand schizophrenia, the concept of clusters of symptoms is often used.

 

Thus, people with schizophrenia can experience symptoms thatmay be grouped under the following categories:

 

  • Positive symptoms - Hearing voices, suspiciousness, feeling under constant surveillance, delusions, ormaking up words without a meaning (neologisms). 
  • Negative (or deficit) symptoms - Social withdrawal, difficulty in expressing emotions (in extreme cases called blunted affect), difficulty in taking care of themselves, inability to feel pleasure (these symptoms cause severe impairment and are often mistaken for laziness.) 
  • Cognitive symptoms - Difficulties attending to and processing ofinformation, in understanding the environment, and in remembering simple tasks 
  • Affective (or mood) symptoms - Most notably depression, accounting for a very high rate of attempted suicide inpeople suffering from schizophrenia

 

Helpful definitions in understanding schizophrenia include the following:

 

  • Psychosis: Psychosis is defined asbeing out of touch with reality. During this phase, one can experiencedelusions or prominent hallucinations. People with psychoses are not aware that what they are experiencing or some of the things that they believeare not real. Psychosis is a prominent feature ofschizophrenia but is not unique to this illness. 
  • Schizoid: This term is often used to describe a personality disordercharacterized by almost complete lack of interest in social relationships and a restricted range of expression of emotions in interpersonal settings, making a person with this disorder appear cold and aloof. 
  • Schizotypal: This term defines a more severe personality disorder characterized by acute discomfort with close relationships as well as disturbances of perception and bizarre behaviors, makingpeople with schizophreniaseem odd and eccentric because of unusual mannerisms. 
  • Hallucinations: A person with schizophrenia may have strong sensations of objects or events that are real only to him or her. These may be in the form of things that they believe strongly that they see, hear, smell, taste, or touch. Hallucinations have no outside source, and are sometimes described as "the person's mind playing tricks" on him or her. 
  • Illusion: An illusion is a mistaken perception for which there is an actual external stimulus. For example, a visual illusion might be seeing a shadow and misinterpreting it as a person. The words "illusion" and "hallucination" are sometimes confused with each other. 
  • Delusion: A person with a delusion has a strong belief about something despite evidence that the belief is false. For instance, a person maylisten to a radio and believe the radio is giving a coded message about an impending extraterrestrial invasion.All of theother peoplewho listento the same radio program would hear, for example,a feature story about road repair work taking place in the area.

 

Types of schizophrenia are as follows:

 

  • Paranoid-type schizophreniais characterized bydelusions andauditory hallucinations but relatively normal intellectual functioning and expression of affect. The delusions can often be about being persecuted unfairly or being some other person who is famous. People with paranoid-type schizophrenia can exhibit anger, aloofness, anxiety, and argumentativeness. 
  • Disorganized-type schizophreniais characterized by speech and behavior that aredisorganized or difficult to understand, andflattening or inappropriate emotions. People with disorganized-type schizophrenia may laugh at the changing color of a traffic light orat something not closely related to what they are saying or doing. Their disorganized behavior may disrupt normal activities, such as showering, dressing, and preparing meals. 
  • Catatonic-type schizophreniais characterized by disturbances of movement. People with catatonic-type schizophreniamay keep themselves completely immobile or move all over the place. They may not say anything for hours, or theymay repeat anything you say or do senselessly. Either way, the behavior is putting these people at high risk because it impairs their ability to take care of themselves. 
  • Undifferentiated-type schizophreniais characterized by some symptoms seen in allof the abovetypes but not enough ofany one of them to define it as another particular type of schizophrenia. 
  • Residual-type schizophrenia is characterized by a past history of at least one episode of schizophrenia, but the person currently has no positive symptoms (delusions, hallucinations, disorganized speech or behavior). It may represent a transition between a full-blown episode and complete remission, or it may continue for years without any further psychotic episodes.

Causes

The causes of schizophrenia are not known. However, an interplay of genetic, biological, environmental, and psychologicalfactors are thought to be involved. We do not yet understand all thecauses and other issuesinvolved, but current research is making steady progress towards elucidating and defining causes of schizophrenia.

 

In biological models of schizophrenia, genetic (familial) predisposition, infectious agents, allergies, and disturbances in metabolism have all been investigated.

 

Schizophrenia is known to run in families. Thus, the riskof illness inan identical twin of a person with schizophrenia is 40-50%. A child of a parent suffering from schizophrenia has a 10% chance of developing the illness. The risk of schizophrenia in the general population is about 1%.

 

The current concept is that multiple genes are involved in the development of schizophrenia and that factors such as prenatal (intrauterine), perinatal, and nonspecific stressors are involved in creating a disposition or vulnerability to develop the illness.

 

Neurotransmitters (chemicals allowing the communication between nerve cells) have also been implicated in the development of schizophrenia. The list of neurotransmitters under scrutiny is long, but special attention has been given to dopamine, serotonin, and glutamate.

 

Also, recent studies have identified subtle changes in brain structure and function, indicating that, at least in part, schizophrenia could be a disorder of the development of the brain.

 

It is important for doctors to investigate all reasonable medical causes for anyacute change in someone's mental health or behavior. Sometimes a medical condition that might be treated easily, if diagnosed, is responsible for symptoms that resemble those of schizophrenia.

Treatment

While there are a number of helpful treatments available, medication remains the cornerstone of treatment for people with schizophrenia. These medications are often referred to as antipsychotics since they help decrease the intensity of psychotic symptoms. Many health-care professionals prescribe one of these medications, sometimes in combination of one or more other psychiatric medications, in order to maximize the benefit for the person with schizophrenia.

 

Medications that are thought to be particularly effective in treating positive symptoms of schizophrenia includeolanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), and asenapine (Saphis).

 

These medications are the newer group of antipsychotic medications, also called second-generation antipsychotics. They are known for having the ability to work quickly compared to many other psychiatric medications.

 

As a group of medications, side effects that occur most often include sleepiness, dizziness, and increased appetite. Weight gain, which may be associated with higher blood sugar levels, elevated blood lipid levels, and sometimes increased levels of a hormone called prolactin, may also occur.

 

Although older antipsychotic medications in this class likehaloperidol (Haldol), perphenazine (Trilafon), and molindone (Moban) are more likely to cause muscle stiffness, shakiness, and very rarely uncoordinated muscle twitches (tardive dyskinesia) that can be permanent, health-care practitioners appropriately monitor the people they treat for these potential side effects as well.

 

Also, more recent research regarding all antipsychotic medication seems to demonstrate that the older (first-generation) antipsychotics are just as effective as the newer ones and have no higher rate of people stopping treatment because of any side effect the medications cause. Not all medications that treat schizophrenia in adults have been approved for use in treating childhood schizophrenia.

 

Mood-stabilizer medications like lithium (Lithobid), divalproex (Depakote), carbamazepine and lamotrigine (Lamictal) can be useful in treating mood swings that sometimes occur individuals who have a diagnosable mood disorder in addition to psychotic symptoms (for example, schizoaffective disorder, depression in addition to schizophrenia).

 

These medications may take a bit longer to work compared to the antipsychotic medications. Some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels, and some can be associated with birth defectswhen taken by pregnant women.

 

Antidepressant medications are the primary medical treatment for the depression that can often accompany schizophrenia. Examples ofantidepressants that are commonly prescribed for that purpose include serotonergic (SSRI) medications that affect serotonin levels like fluoxetine(Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), andescitalopram (Lexapro); combination serotonergic/adrenergic medications (SNRIs) like venlafaxine (Effexor) and duloxetine (Cymbalta), as well asbupropion (Wellbutrin), which is a dopaminergic (affecting dopamine levels) antidepressant.

 

Despite its stigmatized history, electroconvulsive therapy (ECT) can be a viable treatment for people whose schizophrenia has inadequately responded to a number of medication trials and psychosocial interventions.

 

When treating pregnant individuals with schizophrenia, health-care practitioners take great care to balance the need to maintain the person's more stable thoughts and behavior while minimizing the risks that medications used to treat this disorder may present.

 

While some medications that treat schizophrenia may carry risks to the fetus in pregnancy and during breastfeeding, careful monitoring of how much medication is administered and the health of the fetus and of the mother can go a long way to protecting the fetus from any such risks, while maximizing the chance that the fetus will grow in the healthier environment afforded by an emotionally healthy mother.

 

Psychosocial interventions

 

Family psycho-education: In addition to educating family members about the symptoms, course, and treatment of schizophrenia, this form of treatment consists of providing family support, problem-solving skills, and access to care providers during times of crises.

 

When this intervention is consistently provided for at least several months, it has been found to decrease the relapse rate for the individual with schizophrenia and improve the person's social and emotional outcomes.

 

Also, the burden that family members experience as a result of having a loved one with schizophrenia is lessened, family members tend to be more knowledgeable about the disorder and feel more supported by the professionals involved, and family relationships are improved.

 

Assertive community treatment (ACT): This intervention consists of members of the person's treatment team meeting with that individual on a daily basis, in community settings (for example, home, work, or other places the person with schizophrenia frequents) rather than in an office or hospital setting.

 

The treatment team is made up of a variety of professionals. For example, a psychiatrist, nurse, case manager, employment counselor, and substance-abuse counselor often make up an ACT team. ACT tends to be successful in reducing how often people with schizophrenia are hospitalized or become homeless.

 

Substance abuse treatment: Providing medical and psychosocial interventions that address substance abuse should be an integral part of treatment as about 50% of individuals with schizophrenia suffer from some kind of substance abuse or dependence.

 

Social skills training: Also called illness management and recovery programming, social-skills training involves teaching clients ways to handle social situations appropriately. It often involves the person scripting (thinking through or role-playing) situations that occur in social settings in order to prepare for those situations when they actually occur.

 

This treatment type has been found to help people with schizophrenia resist using drugs of abuse, as well as improve their relationships with health-care professionals and with people at work.

 

Supported employment: This intervention provides supports like a work coach (someone who periodically or consistently counsels the client in the workplace), as well as instruction on constructing an interviewing for jobs, and education and support for employers to hire individuals with chronic mental illness. Supported employment has been found to help schizophrenia sufferers secure employment, earn more money, and increase the number of hours they are able to work.

 

Cognitive behavioral therapy (CBT): CBT is a reality-based intervention that focuses on helping a client understand and change patterns that tend to interfere with his or her ability to interact with others and otherwise function. Except for people who are actively psychotic, CBT has been found to help individuals with schizophrenia decrease symptoms and improve their ability to function socially. This intervention can be done either individually or in group sessions.

 

Weight management: Educating people with schizophrenia about weight gain and related health problems that can be a side effect of some antipsychotic and other psychiatric medications has been found to be helpful in resulting in a modest weight loss. That is also true when schizophrenia sufferers are provided with behavioral interventions to assist with weight loss.

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