original Indian

What is Schizophrenia ?

Schizophrenia is fundamentally a physical disease of the brain like Alzheimer's. In fact its first name was "dementia praecox", meaning "early dementia". You can look at schizophrenia as a neurodegenerative illness, meaning people experience a slow continuing deterioration as they get older, like Alzheimer's, and this is true for some people with schizophrenia, but it is more commonly thought of as a neurodevelopmental illness, present at birth, affecting neurological development, and becoming manifest in late adolescence, probably because of the prefrontal cortex maturation at that time. You will still see schizophrenia described simply as a chemical imbalance in the brain but there is a whole lot more to it than that, including changes in brain structure and function. One of the first documented was the enlarged ventricles that were first seen in CAT scans, indicating a brain that has atrophied to some extent. At a minimum, schizophrenia involves changes in the structure and/or function of the hippocampus, the prefrontal cortex, and the thalamus. There is a lot more to this dimension of schizophrenia that I don't know very much about. From what I understand, most of what is known about schizophrenia has been learned in the last 20 years. I do know that schizophrenia is quite common relative to other disabling conditions but so highly stigmatized the general public knows very little about it. Whatever it actually is, the statistics have historically been pretty grim.
· 1% of the population develops the illness
· 40% attempt suicide and 10% die by suicide
· 50% develop a substance abuse problem in their lifetime
· 50% can't accept or don't believe they have a psychotic disorder
· most people stop taking their medication at least once
· 70% of those who go off their medication have to be rehospitalized within two years because they are in psychosis
· 33% of the homeless have an untreated psychotic disorder
Essentially, the longer you are in psychosis, the more likely you will become homeless or incarcerated in jail if you are not hospitalized and/or treated with antipsychotics. Untreated schizophrenia always leads to psychosis. It's just a question of how long it takes. Untreated psychosis leads to hospitalization, incarceration or homelessness, if it isn't treated with medication. Anything else probably isn't schizophrenia.
There is a fairly strong genetic component in schizophrenia, but in genetically identical twins, the probability of both developing schizophrenia if one does is only 50%. The genetics of schizophrenia are thought to involve multiple genes but if there is a family history the risk of developing it increases. Another angle on genetic causation is when the father of a child is quite old at the conception of a child. As men age their sperm DNA can become damaged.
Many psychiatrists believe schizophrenia could be four or five different illnesses that look alike. There is a lot of variation between individuals. A common differentiation is whether onset is fairly sudden or insidious (gradual). The brain is still basically an uncharted universe. No one really understands what causes schizophrenia. At a conference I went to in 1996 the following slide, was shown: Bipolar disorder (manic depression), is a related condition that also has episodes of delusions and hallucinations in periods of mania but it is considered a mood disorder. Depression itself, which is a very common mood disorder, often has psychotic features of reality distortion. Schizophrenia is generally the most disabling of the three. Quite a few people are diagnosed with schizo affective disorder which has some symptoms of both schizophrenia and bipolar disorder, and it is almost fair to think of schizophrenia and bipolar disorder as being two ends of a continuum with depression as yet another axis. They are genetically related as well. You could have a relative who developed bipolar and you might develop schizophrenia. Substance abuse can cause psychosis but it generally clears up when the substance abuse stops,and depression can be experienced with psychotic features. There are in fact something like a hundred medical conditions that can involve psychosis including high fevers, sleep deprivation, etc. There is usually much more than just psychosis to schizophrenia, that has historically made schizophrenia a very disabling illness to live with.
Descriptions of conditions like schizophrenia started to appear in Europe around 1850 and Kraepelin in 1878 followed by Beuler in 1908 described it quite well. Beuler coined the term "the schizophrenias", meaning literally "split mind", - not to be confused with split personality, which is entirely different. He must have thought there was more then one kind. It has probably been around for a much longer time though, because it has a fairly even distribution around the world. Rich and poor, male and female, about one per cent of any population develops schizophrenia.
There was no effective treatment until 1954 when Chlorpromazine was tried. Similar antipsychotics or "major tranquilizers" as they used to be called, soon followed. They had a limited success, there being few drugs disliked as much as Haldol, which was the most commonly prescribed for schizophrenia. The new atypical drugs are more effective over a broader range of symptoms with fewer unpleasant side effects. Used in combination with early diagnosis they are a major advance in the treatment of schizophrenia. There is no known cure for schizophrenia, only relief from symptoms with continued use of medication and a stress free environment. The psychotic episodes are increasingly seen as "toxic". Delays in treatment and subsequent episodes tend to damage brain functioning and result in greater disability. The response to medication is always best during the first psychotic break and usually diminishes with delays and relapses. It is very important to treat early with atypical medication and avoid relapses because of this.
Symptoms
If you are new to schizophrenia you might want to read one of the following pamphlets written by the National Institute for Mental Health, or the Royal College of Psychiatrists respectively
A period of severe depression sometimes precedes the first emergence of schizophrenia in late adolescence. Substance abuse is also quite common before the first psychotic break. The prodromal symptoms are a period of lower functioning that can begin years before the first psychosis. It often means a lot of emotional turmoil for the individual as they struggle to keep their grades up and maintain their relationships. The prodrome is usually only recognized in hindsight though. A psychosis is characterized by a lot of reality distortion and disorganization. Schizophrenia is not a simple illness. There are actually three or four clusters of symptoms:
positive - negative - cognitive - mood

Psychosis is characterized by positive symptoms: hallucinations like hearing voices, delusions of persecution or grandiosity, disorganized speech and thought, altered sense of self and often bizarre behaviour. In a psychotic episode people behave out of character and can be a danger to themselves, the general public, and even the people they love, so they are often hospitalized for treatment. Such an individual is having difficulty maintaining contact with reality. There is a loosening of associations that can make an individual in psychosis quite unpredictable and virtually impossible to communicate with. Psychosis is not an on-off switch though, and the degree of psychosis can be quite severe, or mild or anywhere in between. The voices and delusions are very real sensory experiences for the individual and they usually don't see them as a disease process. They are called positive because they are added on to the individuals experience and behavior. It can be virtually impossible to reason with such an individual. They can be beyond reason. Depending on the degree of psychosis they will require prompt treatment and often hospitalization. Psychosis is like a heart attack. It's best if the duration of untreated psychosis is kept to a minimum.
Negative symptoms are deficit symptoms, experience and behaviour that should be there and is not, like a loss of motivation, flattened emotions, withdrawal from an active social life, poverty of thought and speech, loss of former interests and pleasures. They become more apparent once the positive symptoms have responded to medication although they probably developed years earlier during the prodrome. It is actually the illness, not the individual's natural character. These symptoms and cognitive symptoms are prefrontal cortex activities which are diminished in schizophrenia.
The loss of cognitive abilities, are sometimes lumped with other negative symptoms, because they are also deficit symptoms. These symptoms are thought to predict long term outcome, essentially, how well an individual is going to recover from schizophrenia. Cognitive abilities are uniquely human abilities of perception, memory, abstract reasoning, vigilance, and planning that are essential in such things as employment.
Mood symptoms like depression, are the main reason for the high rate of attempted suicide in schizophrenia. Because negative symptoms can look a lot like depression physicians may not recognize the depression as distinct from the schizophrenia.
Some researchers divide up symptoms a little differently, (a) reality distortion, (b) deficit symptoms and (c) disorganization symptoms. There is considerable individual variation in symptoms experienced, but almost everyone diagnosed with schizophrenia has heard auditory hallucinations in some form or other, usually voices. They are the classic symptom of schizophrenia. The voices inside and/or outside one's head are often derogatory and frightening. You have probably seen someone in dirty clothes, homeless, on a street corner talking to the wind, maybe shaking their fist at the sky. I never knew why they were acting that way as I was growing up, but now, having done similar things myself, I can see they were probably tormented by the voices they are hearing and arguing back.
Medication is most effective with the reality distortion symptoms and less effective against others, although the atypicals have some impact on all of them.
Course and Outcome
Some researchers say that 15% of the people diagnosed with schizophrenia experience one psychosis and recover fully. From what I've seen, that is a little high. It is quite difficult to diagnose a first psychosis. Some adolescents do have one psychosis and after a year their psychiatrist may gradually reduce their medication to nothing, and they can do alright. That is the exception rather than the rule. The response to medication varies considerably from individual to individual and a significant percentage of people (10%-15%) are treatment refractory, naturally or because of repeated psychoses, and that is when Clozapine is tried and it helps about 30% of those treatment refractory people.
I think a stress/buffer model for the treatment of schizophrenia is fairly accurate. Increasing stress can be tolerated, provided there are adequate buffers. Medication is a major buffer and often means the individual can live in the community. With a good response to medication the other buffers will hopefully fall into place and where response is not so good I think its time to provide good financial support, adequate housing, family support, opportunities for meaningful activity, social networking, and insight through education.
About fifty per cent of the people with schizophrenia can expect to have a substance abuse problem in their lifetime. No one is quite sure why. Often drug and alcohol abuse exacerbate symptoms. For a long time nobody wanted to work with those people. The addiction people wouldn't take them and the psychiatric hospitals wouldn't take them. It was a major gap in the mental health system that still exists to some degree.
One critical fact of schizophrenia to realize is that it interferes with self awareness. According to Dr. Fuller Torrey fifty per cent of the people diagnosed with a psychotic disorder either don't know or refuse to believe they have a treatable illness. They often stop taking their medication - when they are feeling better, or when the side effects are too unpleasant and they almost always relapse and have another psychotic episode.
Governments have not been very compassionate to people who develop schizophrenia. The impact and cost of the illness is not fully appreciated and resources are not utilized optimally. Dr. Fuller Torrey claims that the L.A. county jail houses more people with schizophrenia than any psychiatric hospital in the US. People taking appropriate medication, are very unlikely to get in trouble with the law. A surprising number of people with schizophrenia and bipolar disorder are not receiving treatment at any given time and this has never been fully addressed by governments.
There is a very promising trend these days to an early diagnosis with prompt treatment with new atypical medications which treat positive, negative, mood and cognitive symptoms and those people seem to recover very well, especially with family education and community support. I expect they will be able to return to a much more normal life. They seem to suffer very little disability because their illness was "nipped in the bud". I have heard researchers say that in the next ten years they will have drugs ten times better than what they have now, that essentially there will be control of this illness such that people with schizophrenia will be able to lead relatively normal lives.
It is none the less a serious and potentially very destructive illness, that is not understood very well by anyone. There is a lot of suffering associated with schizophrenia, and it has historically been so disabling that something like 80-90% of the people with schizophrenia never marry, or work full time. Some have quite poor recoveries, and they need services to help them live day to day in the community. Because you tend to lose human relationships with schizophrenia people often live quite isolated lives in the community. We live in such an accomplishment oriented society, such a competitive society. People with schizophrenia often find they have been excluded from community life.