Schizophrenia is a chronic brain disease.
There may be several psychotic episodes.
During psychotic episodes a person loses contact with reality.
The disease is caused by abnormalities in the chemicals (neurotransmitters) in the brain.
The symptoms of the illness can be treated and controlled, but the condition is incurable.
What is schizophrenia?
One of the most misused psychiatric terms is the word "schizophrenia". This disease is often incorrectly used to describe a person with a "split personality". This, however, is a total misconception.
Schizophrenia is a serious disorder of the brain that affects how people think, feel and act. Schizophrenia usually appears at a young age (late teens, early twenties) and can cause severe disability and loss of function if not treated correctly. Any person can develop the disorder and it can occur at any age, although it is rare for a person to develop the disorder after the age of 45 for the first time. Emil Kraepelin (1856 - 1936) first described this disease at the beginning of the 20th century and the name "schizophrenia" was used in 1911 by Eugene Bleuler (1857 - 1939).
What are the symptoms?
Symptoms are divided into positive, negative and cognitive categories. Positive symptoms are characterized by delusions, hallucinations, disorganized speech and/or behaviour. Negative symptoms consist of social withdrawal, lack of motivation, emotional blunting and lack of energy. Cognitive symptoms include difficulty with attention, concentration and memory.
Positive symptoms: Hallucinations are abnormalities in perception (person experiences sensations without an outside stimulus) where one may, for example, hear voices speaking outside one's head although there is no one present, or one may see things that do not exist. Delusions are false beliefs that a person firmly hold and cannot be convinced differently, despite logical arguments or proof to the contrary. These beliefs are not in keeping with the person’s own cultural beliefs or background. These thoughts may be based on reality, but with incorrect interpretation of the situation. A person may believe that people are watching him, that everybody is against him or that the television is broadcasting his thoughts to all the people in his neighbourhood.
Negative symptoms: A person suffering from schizophrenia often lacks social interaction with other people. They may become socially isolated and withdrawn to such an extent that they refuse to get out of bed or eat a meal. They may take poor care of themselves and therefore often neglect their personal appearance. These symptoms may often wrongly be interpreted as laziness.
Cognitive symptoms: people with schizophrenia have difficulty in focusing their attention, and concentrating for a long time. They also have difficulty with memory. These symptoms are often most debilitating to people who suffer with schizophrenia.
There are five subtypes of schizophrenia. No two people with schizophrenia are the same. It is a disorder of multiple clinical presentations and there are different levels of severity.
A psychotic episode occurs in four phases:
Premorbid phase: period prior to onset of symptoms.
Prodromal or pre-psychotic phase: early symptoms involving changes in thoughts, feelings and behaviour may occur prior to the onset of the frank psychotic symptoms.
Acute phase: psychotic symptoms, such as hallucinations, delusions, disorganised behaviour and disorganised thinking are experienced.
Residual or recovery phase: acute symptoms have subsided; some odd beliefs, vague abnormal perceptions and negative symptoms may persist.
It is often difficult to differentiate these four phases, and symptoms of psychosis may occur, to varying degrees, in all four.
How common is schizophrenia?
Worldwide it is estimated that 1% of the population may suffer from schizophrenia, but the disorder is more prevalent in families where schizophrenia has previously been diagnosed.
If a person has one parent with the diagnosis of schizophrenia they have a 10% chance of developing the disorder themselves. This percentage increases when both parents are affected. If one has an identical twin with the disorder, one would have an almost 50% chance of developing schizophrenia.
What are the causes of schizophrenia?
Although extensive research is being conducted in this area, the answer is not yet fully known. No definite cause has been identified, but a few theories exist.
Genetic transmission definitely plays a role as is seen in families in which the disorder is prevalent. However, no single gene has been identified as the transmitter of schizophrenia. Theory has it that there is probably a multiple group of genes involved. If one has the “right” combination of defective genes, certain adverse events may act as a trigger, e.g. drug abuse and severe stress or illness.
Studies have also shown that trauma at birth or intra-uterine infections may be a possible cause of schizophrenia in later life. It is also more common in the urban environment and amongst immigrant populations. Smoking cannabis (dagga) as a teenager has also been shown to increase the chances of developing schizophrenia later in life.
The disease involves a dysfunction in neurotransmitters, particularly dopamine (chemical substances involved in transmission of impulses between nerve cells) and serotonin. Certain areas in the brain are defective, especially in the frontal and temporal lobes.
Treatment is focused at reducing symptoms and optimizing the person’s functioning. There is no reason why a person with schizophrenia could not be working and functioning as a member of the community. That is of course once the acute symptoms have been treated successfully.
There are several ways to optimise the treatment and the role of family members and other loved ones must not be underestimated in improving the patient’s quality of life and the outcome of the treatment. Medication, stress management, education and information are integral in improving the treatment of schizophrenia.
The treatment with medication consists of antipsychotic drugs. The antipsychotics initially bring the acute psychosis under control and thereafter prevent further episodes from occurring.
Medications that have been used regularly in the past include haloperidol and chlorpromazine. These older medications are effective in treating the positive symptoms, but less successful in addressing the negative symptoms. They also have undesirable side effects. These include uncontrollable movements, tremors, lethargy, blunted emotions, shuffling gait and staring eyes. Side effects can be minimized by using the correct dose and by taking the medication regularly. Additional medication can be prescribed to offset certain side effects.
In recent years, however, the "new generation" antipsychotics have been developed. These drugs seem to be more effective in reducing social isolation and withdrawal of patients and have been proven to cause significantly fewer movement side effects than their predecessors. They include Risperidone, Quetiapine, Olanzapine, Aripiprazole, Amisulpride and Clozapine. Although they are more expensive, their improved efficacy means less hospitalization and better functioning of the individual, which is priceless. There are, however, still some problematic side effects with the newer medications, including weight gain and diabetes mellitus.
Research continues to produce better medications with fewer side effects and in time we will hopefully be able to treat the disorder more successfully.
In addition to antipsychotics people with schizophrenia can also take Omega 3 fatty acids (fish oils) as they have been shown to improve the outcome of the illness.
As soon as the patient has responded to medication and the abnormal thoughts are under control, psychoeducation should be started.
The goal of psychoeducation is to fully inform the patient and the relatives about the disease and all other aspects of treatment. Topics that should be addressed during psychoeducation are the early recognition of schizophrenia symptoms, the prevention of recurrence of the psychotic episodes, the role of medication and side effects. This information is essential for the patient to understand why he/she needs the medication and have to take medication for the rest of his/her life.
If patients are not adequately informed about potential side effects they may stop using the medication without consulting a psychiatrist for advice. Unfortunately people suffering from schizophrenia often have poor insight into their own condition and may believe they are not ill and do not need to take medication. Discontinuation of medication is one of the most common reasons for relapse and reappearance of symptoms.
To improve compliance to treatment the relatives need to be given as much information about the disorder as possible. In this way they will understand the patient better and therefore be able and willing to help in the long-term encouragement and treatment of the patient. Family education remains one of the most effective therapies in improving long-term outcome, and quality of life of people with schizophrenia.
What is the outcome of schizophrenia?
Earlier treatment usually results in a better outcome. Treatment delays may make the condition get worse, be less responsive to treatment, and make it take longer to go into remission. The lesser the degree of remission, the greater chance of early relapse.
Although this disease has received much negative media attention, it often has a favourable outcome. There have recently been major advances in the treatment of the disorder with the development of the new generation antipsychotics. This gives even more hope for a successful outcome in the treatment of schizophrenia.
When to call a health professional
Call your doctor or mental health professional without delay if you or a friend or family member exhibits behaviour that suggests loss of contact with reality, or if any other symptoms suggestive of psychosis, develop.
Where to go for help
Cape Support for Mental Health gives support to families of people affected by schizophrenia and other prolonged mental illnesses. They can be contacted at (021) 671 1573. Website: www.capesupport.org.za. E-mail: firstname.lastname@example.org.
The Mental Health Information Centre can provide useful information about the illness and where to go for help. They can be found at www.mentalhealthsa.co.za or contacted at 021 9389229
Reviewed by Dr Bonga Chiliza, psychiatrist, Department of Psychiatry, University of Stellenbosch.