Schizophrenia
Schizophrenia is a severe type of psychiatric illness. Its a type of psychotic illness characterised by disorders of thinking, perception, emotion, motivation, and motor activity. It is an illness in which episodes of florid disturbance are usually set against a background of sustained disability. This illness can cause profound difficulty in initiating and organizing activity that can render patients unable to care for themselves.
Symptoms of Schizophrenia
1. Delusions- False fixed beliefs that are not amenable to change in light of conflicting evidence. There are various types of delusions. They are-
• Persecutory Delusion- Belief that one is going to be harmed, harassed and so forth. Eg:- The patient may claim that he is being watched or spied upon using cameras, satellites or mobile phones. He may think that he is being poisoned or others are doing black magic against him.
• Referential Delusion- Belief that certain gestures, comments, environmental cues and so forth are directed to oneself. Eg:- The patient may claim that others are talking ill about him, the weather change is because of him etc. Grandiose Delusion- Belief that he or she has exceptional abilities, wealth or fame. Eg:- The patient may claim that he has the ability to heal others, that he has godly powers etc.
• Erotomaniac Delusion- Belief that another person is in love with him.
• Thought insertion- Belief that thoughts are being inserted into their mind from outside.
• Thought withdrawal- here the patient may believe that his thoughts are being withdrawn by some outside force.
• Thought broadcasting- belief that one’s thoughts are quietly escaping from one’s mind and that other people might be able to access them.
• Delusion of control- belief that one’s body or actions are being controlled by an external agency.
2. Hallucinations- are perception-like experiences that occur without an external stimulus. In Schizophrenia auditory hallucinations (hearing voices without the voices being there in the actual world) are common. The patient may claim that he can hear the neighbours talking about him, abusing and threatening him, when actually there
is nothing like that. After a while the patient may talk back to these voices, which when viewed by others are seen as muttering to self.
3. Disorganized speech- The speech of schizophrenic patients is often difficult to understand because of abnormalities of form of the underlying thought. The abnormalities are-
• Derailment—wandering off the point during the free flow of conversation
• Tangentiality—answers to questions that are off the point
• Incoherence—a breakdown of the relationships between words within a sentence so that the sentence no longer makes sense
• Loss of goal—failure to reach a conclusion or achieve a point.
• Metonyms—unusual uses of words (e.g. hand-shoe instead of glove)
• Neologisms—new words invented by the patient.
• Poverty of speech—a disorder of the flow of speech in which the rate of speech production is reduced
• Poverty of content—the amount of information conveyed is relatively little in proportion to the number of words uttered.
Disorganized Behaviour- Behaviour may vary from childlike silliness or unpredictable agitation, with decreased self-care.
• Mutism – patient may remain mute
• Immobility – absence of motor activity
• Posturing – adopting an unusual body posture
• Waxy flexibility – allowing others to adjust one’s posture, yielding like a warm candle
• Negativism – resisting manipulation by an others, with force proportional to that applied by others
• Stereotypy – aimless repetitive motor behaviour
• Mannerisms – apparently purposeful actions that appear odd because they are exaggerated in form or occur out of the usual context
• Echo phenomena – repetition of others utterances or movements
• Excitement – excessive motor activity, usually accompanied by excessive
Patient and relative were psychoeducated regarding the illness, a definitive management plan was worked out with the client and relative. She was started on Pharmacotherapy (Medicines) – antidepressants and Psychotherapy (CBT). After 4 weeks – up titration of medicines to therapeutic level & 4 CBT sessions, 100% improvement was attained and maintained. No side effects to medicines were reported. She passed 4th year MBBS with good marks & completed her house surgency too. She still remains symptom free and happy, back to her normal self, now practicing as a doctor.
Causes/ risk factors of Schizophrenia
Biological factors
1. Neurotransmitters : Neurotransmitters are chemicals in the brain found between neurons & they help in the transmission of signals from one neuron to another. There are many neurotransmitters like Dopamine, Serotonin, Norepinephrine, GABA,
Acetylcholine, Glutamate, glycine – the balance of which are found disturbed in Schizophrenia, thus altering the signal transmission & thereby the connectivity between different brain regions. In Schizophrenia the main neurotransmitter involved
is Dopamine, which is found in excess.
2. Receptors : Different Neurotransmitters bind to specific receptors on the neurons to transmit the signals. In Schizophrenia, these receptors may be upregulated or downregulated or hypo-functional or hyper-functional for specific neurotransmitters in specific brain regions.
3. Second Messengers and Intracellular Cascades : Each Neurotransmitter after binding to its specific receptor on the neuron, triggers the G Proteins & some enzymes causing the production of 2nd messengers such as cAMP & cGMP, which in turn regulate the
function of neuronal membrane ion channels; thereby regulating the transmission of signals across neurons. In Schizophrenia, this complex machinery is found to be deranged.
4. Structural and Functional Brain Imaging:
• CT & MRI Scans have shown that Schizophrenia damage different parts of the Brain, causing Neurodegenerative changes – Ventricular enlargement, cortical atrophy, sulcal widening & reduced hippocampal or caudate nucleus volumes.
• PET Scans have shown decreased brain metabolism
5. Magnetic resonance spectroscopy : has shown that patients with schizophrenia had lower levels of phosphomonoester and inorganic phosphate and higher levels of phosphodiester.
6. Neural Circuits :
• Dysfunction anterior cingulate basal ganglia thalamocortical circuit underlies the production of positive psychotic symptoms.
• Dysfunction of the dorsolateral prefrontal circuit underlies the production of negative or deficit symptoms.
• Dysfunction of the normal working memory neural circuit underlies the production of cognitive Symptoms like impaired working memory.
7. EEG : decreased alpha activity, increased theta and delta activity.
8. Evoked Potentials : A large number of abnormalities in evoked potential especially P300 has been noted.
9. Alterations of Hormonal Regulation : Various hormones like BDNF, Cortisol, Thyroid hormone, Growth hormone are found to be dysregulated in Schizophrenia.
10. Immunological Disturbance : decreased T-cell interleukin-2 production, reduced number and responsiveness of peripheral lymphocytes, abnormal cellular and humoral reactivity to neurons, and the presence of brain-directed (antibrain) antibodies.
Genetic Factors
1. Family Studies : If one parent has Schizophrenia, the child will have a risk of 10-25%. If both parents have mood disorder, this risk is 50% The more members of the family are affected, the greater the risk is to a child. The risk is greater if the affected family members are first-degree relatives rather than more distant relatives.
2. Twin Studies : If one Monozygotic (identical) twin has Schizophrenia, there is 47% risk that the other twin will develop the same disorder. In the case of Dizygotic (fraternal) twins, the risk is 10-15%.
Psychosocial Factors
1. Life Events and Environmental Stress : Stressful life events more often precede the development of Schizophrenia. Stress results in long-lasting changes in the brain’s biology- alter the Neurotransmitter balance, intraneuronal signalling systems & even loss of neurons and synaptic contacts, increasing the susceptibility to Schizophrenia.
Diagnosing Schizophrenia
Schizophrenia is diagnosed by conducting a –
1. Psychiatric interview- of the client (patient) & informants (relatives). A detailed history of the complaints & the present illness, past history of psychiatric illness, family history to see if there are any genetic predisposing causes, personal history to see if any marital/relationship problems or any substance use like alcohol or if there are any external stressors like job loss contributing to the present illness, general medical history to rule out any possibility of any physical illness (like hypothyroidism/ vitD3 deficiency/parkinsonism/Dementia) contributing to the present illness, assessment of personality to see if any personality traits or personality disorder is contributing to the current episode of illness.
2. Mental Status examination- General appearance & behaviour, Psychomotor activity, Talk, Thought, Mood, Affect, Perception, Cognitive functions- attention & concentration, memory, intelligence, abstractability, judgment & insight are assessed.
3. Physical Examination- to see if the patient has any undiagnosed medical condition or neurological condition contributing to the present psychiatric illness.
4. Neuro-Psychiatric assessment scales- rating scales to have an objective measurement
Investigations
• Blood levels of Thyroid hormones, Blood vitamin, Blood sugar levels Liver & kidney function tests.
• MRI Brain to rule out any neurological causes for the present illness.
• EEG: to rule out any seizure disorders which may co-exist with or mimic schizophrenia.
Treatment of Schizophrenia
A. Pharmacotherapy- It’s the treatment by using medicines- Antipsychotics. Medicines correct the neurochemical imbalances, the receptor dysregulations, 2nd messenger & intracellular disarray, stops neuronal loss, increases neuronal dendritic spines and reestablishes neuronal synaptic connections and thus improves and normalises connectivity of different brain regions, thus improving the positive, negative & cognitive symptoms of schizophrenia. CT, MRI, PET & FMRI studies have shown that treatment with drugs have a positive rebuilding effect on the brain. Antipsychotics are safe, efficacious and are not addictive. Most of the antipsychotics have no to minimal side effects. The duration of treatment depends on the duration of the illness, its severity, no of psychotic episodes etc. It’s important to complete the full course of treatment and not to stop treatment after mere resolution of symptoms as premature termination of treatment can lead to illness recurrence. After each episode of psychosis, the illness severity increases, frequency of the episodes increases and the response to treatment decreases and thus there will be more residual symptoms.
B. Psychotherapy- Psychotherapy is the treatment by psychological means to overcome the patient’s problem. There are 3 types of psychotherapy which are useful in depression.
1. Cognitive Behaviour Therapy (CBT)- Correcting cognitive distortions
2. Individual Psychotherapy
3. Personal Therapy
4. Dialectical Behaviour Therapy (DBT)
Reference:
1. Oxford Textbook of Psychiatry
2. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry
3. The ICD-10: Classification of Mental and Behavioural Disorders
4. Diagnostic and Statistical Manual of Mental Disorders (DSM–5)
5. https://www.ncbi.nlm.nih.gov/pmc/
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