What is schizophrenia and who gets it?

Schizophrenia is a complex mental illness. Symptoms include hallucinations (such as hearing voices), false beliefs (delusions - misinterpretation of others actions), irrational thoughts, emotional and behaviour disturbances.
People with schizophrenia believe in their delusions as if they are real and do not know which thoughts and experiences are true or real and which are not. The patients react to these false beliefs and feel anxious, afraid, fearful, depressed and sometimes even angry. On other occasions, these patients act on those false beliefs and do things that can be harmful to them, like wander away or harm themselves or become violent. Patients believe that something or someone is controlling their thoughts or watching their actions constantly through secret cameras, or following them wherever they go.
 The patients at times hear voices and try to talk to those voices, argue with the voices or follow the command of the voices. Other times, these voices appear to be of known or unknown people talking to themselves about the patient.
Some people have misconceptions about schizophrenia. It is NOT SPLIT PERSONALITY. Also, the people suffering with schizophrenia are not violent.
Schizophrenia develops in about less than 1 in 100 people. It can occur in men and women. The most common ages when schizophrenia starts to develop are 15-25 in men and 25-35 in women.

How does schizophrenia develop?

In most people, Schizophrenia starts very slowly. During normal days, patients may experience oddities in thoughts, sometimes being puzzled about things happening around them. Gradually, these patients try to analyse and start to think about these puzzled things and start withdrawing from reality and society. They start to talk less, socialize less and try to be emotionally unreactive or inappropriate. they will be less motivated, lethargic or lazy showing no interest in day to day activities. It is then they start to suspect others motives or actions which then goes on to develop into persecutory delusions( that people are planning/conspiring to harm them or their family in some way. Later they start to hear voices.
In some others, within a few hours or days, the above symptoms develop rapidly and the patients becomes very distressed and uncontrollable.

What are the symptoms of schizophrenia?

Delusions. These are false beliefs (misinterpretion of other peoples actions) that a person suffers from which are unexplainable and irrational which the person believes despite evidence to the contrary. Even when the wrongness of the belief is explained, a person with schizophrenia is convinced that they are true. For example, a person with schizophrenia may believe that some people are spying on them, following them or are planning to harm them or their family members or that people are plotting to kill them, or there is a conspiracy about them.
Hallucinations. This means hearing, seeing, feeling, smelling, or tasting things that are not real. Hearing voices is the most common. Some people with schizophrenia hear voices that provide a running commentary on their actions, argue with them, or repeat their thoughts. The voices often say things that are rude, aggressive, unpleasant, or give orders that must be followed. Some people with schizophrenia appear to talk to themselves as they respond to the voices. People with schizophrenia believe that the hallucinations are real.
Disordered thoughts. Thoughts may become jumbled or blocked. Thought and speech may not follow a normal logical pattern. For example, some people with schizophrenia have one or more of the following:

  • Thought echo. This means the person hears his or her own thoughts as if they were being spoken aloud.
  • Disordered thinking. This means the person moves from one train of thought to another that has no apparent connection to the first.
  • Thought insertion. This is when someone believes that the thoughts in their mind are not their own and that they are being put there by someone else.
  • Thought withdrawal. This is when someone believes that thoughts are being removed from their mind by an outside agency.
  • Thought broadcasting. This is when someone believes that their thoughts are being read or heard by others.
  • Thought blocking. This is when there is a sudden interruption of the train of thought before it is completed, leaving a blank. The person suddenly stops talking and cannot recall what he or she has been saying.

Lack of motivation.Everything seems an effort - for example, tasks may not be finished, concentration is poor, there is loss of interest in social activities and the person often wants to be alone.
Few spontaneous movements and much time doing nothing.
Facial expressions do not change much and the voice may sound monotonous.
Changed feelings. Emotions may become flat. Sometimes the emotions may be odd, such as laughing at something sad. Other strange behaviours sometimes occur.

Sometimes people neglect themselves. They may not care to do anything and appear to be wrapped up in their own thoughts. Schizophrenia symptoms can also lead to difficulty with education, which can contribute to difficulties with employment. For families and carers, the negative symptoms are often the most difficult to deal with. Persistent negative symptoms tend to be the main cause of long-term disability.
Families may only realise with hindsight that the behaviour of a relative has been gradually changing. Recognising these changes can be particularly difficult if the illness develops during the teenage years when it is normal for some changes in behaviour to occur.

How is the diagnosis made?

Some of the symptoms that occur in schizophrenia also occur in other mental health conditions such as depression, mania, or after taking some street drugs. Therefore, the diagnosis may not be clear at first. As a rule, the symptoms need to be present for several weeks before a doctor will make a firm diagnosis of schizophrenia.
Not all symptoms are present in all cases. Different forms of schizophrenia occur depending upon the main symptoms that develop. For example, people with paranoid schizophrenia mainly have positive symptoms which include delusions that people are trying to harm them. In contrast, some people mainly have negative symptoms and this is classed as simple schizophrenia. In many cases there is a mix of positive and negative symptoms.
Sometimes symptoms develop quickly over a few weeks or so. Family and friends may recognise that the person has a mental health problem. Sometimes symptoms develop slowly over months and the person may gradually become withdrawn, lose friends, jobs, etc, before the condition is recognised.

What is the cause of schizophrenia?

The exact cause is not known. It is thought that the balance of certain brain chemicals (neurotransmitters) is altered. Neurotransmitters are needed to pass messages between brain cells. An altered balance of these may cause the symptoms. It is not clear why changes occur in the neurotransmitters.

What are the treatments for schizophrenia?

Some people need to be admitted to hospital for a short time. This is sometimes done when the condition is first diagnosed so that treatment can be started quickly. Hospital admission may also be needed for a while at other times if symptoms become severe. A small number of people have such a severe illness that they remain in hospital long-term.
People with schizophrenia often deny that they are ill or do not realise or accept that they are ill. Therefore, sometimes when persuasion fails, some people are admitted to hospital for treatment against their will by use of the Mental Health Act. This is only done when the person is thought to be a danger to themself or others.

Antipsychotic medication

The main medicines used to treat schizophrenia are called antipsychotics. They work by altering the balance of some brain chemicals (neurotransmitters). Antipsychotic medication is used to relieve the symptoms. Antipsychotic medicines are also used to prevent recurring episodes of symptoms (relapses). Therefore, antipsychotic medication is usually taken on a long-term basis. There are various antipsychotic medicines and different ones may be used in different circumstances. They are broadly divided into two categories:

  • Newer or atypical antipsychotics: They include amisulpiride, aripiprazole, blonanserin, clozapine, olanzepine, quetiapine, and risperidone. These medications have lesser sideffect profiles compared to typical antipsychotics and are usually well tolerated.
  • Older typical antipsychotics: They include chlorpromazine, trifluperazine, haloperidol, flupenthixol, and zuclopenthixol.

There are some differences between the various antipsychotic medicines. A Psychiatrist usually advises on which is the best suited medication tailored to the patients needs and response.
A good response to antipsychotic medication occurs in about 7 in 10 cases. However, symptoms may take 2-4 weeks to decrease after starting medication and it can take several weeks for full improvement. Even when symptoms decrease, antipsychotic medication should be continued for long-term or till the psychiatrist advices to stop the medication. This is to prevent relapses, or to limit the number and severity of relapses. However, if you only have one episode of symptoms that clears completely with treatment, one can stop medications after 1-2 years. Your doctor will advise.

  • Depot injections of an antipsychotic medicine. In some cases, an injection of a long-acting antipsychotic medicine is used once symptoms have decreased. The medicine from a depot injection is slowly released into the body and is given every 2-4 weeks. This aims to prevent relapses. The main advantage of depot injections is that you do not have to remember to take tablets every day or in some patients who stop taking tablets or find taking tablets very cumbersome on daily basis.

What about side-effects from antipsychotic medicines?

Side-effects can sometimes be troublesome. There is often a trade-off between decreasing symptoms and having to bear with some side-effects from the treatment. The different antipsychotic medicines can have different types of side-effects. Also, sometimes one medicine causes side-effects in some people and not in others. Therefore, it is not unusual to try two or more different medicines before one is found that is best suited to an individual.
The following are the main side-effects that sometimes occur.

  • Common side-effects include: dry mouth, blurred vision, flushing and constipation. These may ease off when you get used to the medicine.
  • Drowsiness (sedation) may occur and may be an indication that the dose is too high. A reduced dose may be an option.
  • Some people develop weight gain. Weight gain may increase the risk of developing diabetes and heart problems in the longer term.

Movement disorders develop in some cases. These include:

  • Parkinsonism - this can cause symptoms similar to those that occur in people with Parkinson's disease. For example, tremor and muscle stiffness.
  • Akathisia - which is like a restlessness of the legs.
  • Dystonia - which means abnormal movements of the face and body.
  • Tardive dyskinesia -which is a movement disorder that can occur if you take antipsychotics for several years. It causes rhythmical, involuntary movements. These are usually lip-smacking and tongue-rotating movements, although it can affect the arms and legs too. About 1 in 5 people treated with typical antipsychotics eventually develop tardive dyskinesia.

Atypical antipsychotic medicines are less likely to cause movement disorder side-effects compared to typical antipsychotic medicines. Reduced incidence of movement disorder is the main reason why an atypical antipsychotic medicine is often used first-line. If movement disorder side-effects occur then other medicines may be used to try to counteract them.

Family Therapy and Education

This may be offered and consists of about 10 therapy sessions for relatives of patients with schizophrenia. It has been found to reduce hospital admissions and the severity of symptoms for up to two years after treatment.

Encouraging physical health

Smoking, lack of exercise, obesity and an unhealthy diet are more common than average in people with schizophrenia. Weight gain may be a side-effect of antipsychotic medicines. All of these factors may lead to an increased chance of developing metabolic syndrome, heart disease and diabetes in later life.
Therefore, as with everyone else in the population, people with schizophrenia should be encouraged to adopt a healthy lifestyle - not to smoke, to take regular exercise, to eat healthily, etc.

What is the outlook (prognosis)?

  • In about 60% of cases there are recurring episodes of symptoms (relapses). Most people in this group live relatively independently with varying amounts of support. The frequency and duration of each relapse can vary. Some people recover completely between relapses. Some people improve between relapses but never quite fully recover. Treatment often prevents relapses, or limits their number and severity.
  • In 20% of cases, there is only one episode of symptoms that lasts a few weeks or so. This is followed by a complete recovery, or substantial improvement without any further relapses.
  • In another 20% with schizophrenia, they are not helped much by treatment and need long-term rehabilitation and dependent care.

The outlook is thought to be better if:

  • Treatment is started soon after symptoms begin.
  • Symptoms develop quickly over several weeks rather than slowly over several months.
  • The main symptoms are positive symptoms rather than negative symptoms.
  • The condition develops in a relatively older person (aged over 25).
  • Symptoms decrease well with medication.
  • Treatment is taken as advised (that is, compliance with treatment is good).
  • There is good family and social support which reduces anxiety and stress.
  • Abuse of illegal drugs or alcohol does not occur.

Compared to the treatment options and response before 1990 and after 1990, the newer medicines and better psychological treatments have made dramatic improvements and changes to the overall symtoms reduction and quality of life of patients suffering from schizophrenia.