What is Schizophrenia?
Dr. R. V. Shirvaikar,
Schizophrenia
Most of the educated peopie who read newspapers, magazines and watch scientific programmes on T.V. are aware of schizophrenia as a major mental disorder, formerly known as insanity, because of the unusual, queer and eccentric behaviour of the patient and because it appears out of this world. Such patients are branded as ‘mad’ and are rebuked and ridiculed by uncultured people. This pushes such unfortunate victims of severe mental disorder deeper into the process of desocialisation, which later affects the patient’s social rehabilitation after treatment.
It is therefore absolutely necessary for the guardians of psychiatric patients and responsible people in general to know what really is meant by schizophrenia. Is it incurable? Should such patients be treated as outcasts, like ‘lepers’ who were ostracised in the last century or like AIDS patients who are condemned these days! Family members of such mental patients suffer not only from the patient’s behaviour and the uphill task of giving him regular treatment but also from the prejudiced community by way of a near boycott.
Schizophrenia, though a difficult mental disorder to cure, is quite treatable by easily available modern treatment methods. Most of such patients improve sufficiently enough to return to their original position in the society.
The concept of schizophrenia is still not definite even in scientific circles. Its definition differs from country to country and has therefore become a very controversial issue; though there is some agreement about its causes, symptoms, course and treatment.
Historical Overview of the Concept
The very first reference to a severe mental disorder was made in Ayurveda as early as in 1400 B.C. However, in modern times the earliest description of schizophrenia as illness was made in late 18th century. The first scientific description of such an illness was made by Morel in 1856. He called it “Demenca Precocie”. He mentioned negative symptoms (social withdrawal and inactivity) and ultimate deterioration of personality in adolescents.
Kahlbaum (1868) described ‘katatonie’, equivalent to ‘catatonia’ (with rigid postures, mutism and impulsivity). Soon afterwards Hecker (1871) described ‘Hebephrene’ equivalent to Hebephrenia of today, with oddities in speech and conduct.
The first valid description of schizophrenia, as it is understood today, was made by E-Kraepelin in Germany in 1896 calling it ‘Dementia Praecox, meaning premature intellectual deterioration. He classified major mental disorders into two main groups, viz, Manic Depressive Insanity and Dementia Praecox. He incorporated the diseases described by Kahlbaum (Katatonie) and Hecker (Hebephrenie) as the types of Dementia Praecox. He also added another type of his own, viz. Dementia Paranoidies (equivalent to Paranoid Schizophrenia). He speculated that this was a brain disorder of unknown pathology, causing intellectual deterioration after some years. This was earlier suggested by Griesinger in 1845. Most of the psychiatrists in Europe, UK and USA could not accept this classification because of its poorly known etiology and pathology. Bleuler, a Swiss psychiatrist, developed Kraepelin’s concept of Dementia Praecox and called it ‘schizophrenia’ in 1911 for the first time. He emphasized its psychogenic origin. Hence the Latin term for “split mind”. He was influenced by the theories of Sigmund Freud, the father of psychoanalysis and stated that the disease meant ‘loosening of associations’ between the different mechanisms of the mind. He named the main symptoms of schizophrenia as ‘Fundamental symptoms’ which were later described as “Four A’s”. They were: 1. Loosening of Associations, 2. Blunting and Incongruity of the emotional apparatus of “Affect”, 3. Autism (shutting off from the social environment and blocking of communication), 4. Ambivalence (love and hate relationship with parents). Other symptoms of hallucinations (perception in the absence of sensation), delusions (false and firm beliefs) were called accessory phenomena of lesser importance. He also added ‘simple schizophrenia’ to the three types viz. Hebephrenic Catatonic and Paranoid, as described by Kraepelin, to constitute one disease entity of schizophrenia. These ideas were widely accepted in the USA because of the Psychoanalytical bias there.
As the boundaries of Bleuler’s schizophrenia were loose, many other syndromes having such symptoms were diagnosed as schizophrenia in the USA, whereas Kraepelin’s concept was accepted and followed more in U.K. and Europe, with the result that the number of cases diagnosed as schizophrenia were much lesser in UK than in USA.
In 1960 Langfeldt differentiated Schizophrenia from Schizophrenieform psychosis to explain the variability and inconsistency of these disorders. He found that, ECT and Insulin Therapy (prevailing then; now out of vogue) were ineffective in true schizophrenia. The latter was called Process Schizophrenia.
Elgin, Phillips and Kantor devised rating scales to differentiate between Process (True) and Non-Process Schizophrenia on the basis of premorbid personality and psychosocial adjustment. Poor prognosis was stated as the feature distinguishing Process schizophrenia from Non-Process Schizophrenia. The former was hereditary and endogenous, whereas the latter was psychogenic and exogenous. Kraepelin believed that schizophrenia was endogenous and hereditary with prevalence of hallucinations and delusions, poor prognosis. They ultimately became chronic and true symptoms of dementia followed later. This was found to be the result of herding together of chronic patients with patients of good prognosis in mental hospitals.
K. Schneider (1959) propounded a new concept of schizophrenia and described first rank symptoms viz, auditory hallucinations and insertion of undesirable thoughts by other persons (due to loss of Ego Boundaries), thought broadcasting (thoughts shared by others), and delusional misinterpretation of real perception. His second rank symptoms were perplexity, emotional blunting, other kinds of (nonauditory) hallucination and delusions.
In the sixties and early seventies, there were different concepts of schizophrenia all over the world, thus lacking in a standard definition of schizophrenia. So in 1973, WHO organised a project of “International” study of schizophrenia in Colombia, Czechoslovakia, Denmark, India, Nigeria, Taiwan, UK, USA and USSR.
The last two countries had a broader concept of schizophrenia resulting in it’s over diagnosis. Subsequently, tendency to diagnose on the basis of symptoms and its course became rudimentary because etiology was neither clear nor confirmed.
Different countries followed different definitions of schizophrenia, and duration and mode of onset were considered to be better. Diagnostic aids than the symptoms of acute illness. Now it is almost agreed by various defining institutions that duration of symptoms must be at least for one month.
At present, the most widely used definitions of schizophrenia, at least for research purposes, are the St. Louis Criteria (Feighner eta11972), the Research Diagnostic Criteria (RDC) (Spitzev etal 1975) and the American Psychiatric Association’s DSM IV (1994) Criteria as well as W.H.O’s lCD 10 Criteria (1992).
They all require clear evidence of psychosis at present or in the past and all but the Feighner Criteria specify particular kinds of hallucinatory experiences or delusional ideation. All the four stipulated that affective symptoms must not be prominent and all require a minimum duration of illness. (Only 2 weeks for RDC definition), 1 month for lCD and 6 months for Feighner. All definitions are arbitrary, justified only by their usefulness. They are liable to be altered or supplemented.
Though schizophrenia and its types are discussed as a single disease, it probably comprises a group of disorders with heterogeneous causes, and definitely includes patients whose clinical picture, treatment responses and defined causes of illness are varied.
Mayergrom defined schizophrenia as a group of mental illnesses characterised by specific psychological symptoms and, in the majority of cases, leading to a disorganisation of the patient’s personality.
Some of the recent etiological themes are –
1.Dopamine hypofunction in mesofrontal areas of the brain are associated with manifestations of negative symptoms.
2.There is Computer Tomographic evidence of cerebral atrophy, enlarged ventricles causing extensive cognitive impairment in schizophrenia with negative symptoms which are often unresponsive to neuroleptic treatment.
What schizophrenia should mean to ordinary folks?
After this explanation of the scientific concepts and definition of schizophrenia I have to write about what schizophrenia should mean to ordinary people especially parents and close relatives or friends of persons diagnosed to be afflicted with schizophrenia.Unfortunately, even today schizophrenia is regarded with great prejudice, abhorrence and apprehension just like leprosy in the last century and AIDS in recent years.
Whereas we all must understand the implications of such a diagnosis in adolescents and young adults and take prompt therapeutic measures, it is equally important that we show a realistic and healthy attitude of sympathy, courage as well as determination to do everything possible to help doctors to bring the patient out of the snake pit as early as possible. The patient as well as his guardians should remember that there is a possibility that the diagnosis is incorrect. Fears of incurability are exaggerated by rumors and hearsay.
Indian research has identified a disorder named Acute Psychotic Disorder which is often mistaken for acute schizophrenia (Wig & Singh, ICMR). The lCD classification also contains another disorder named Acute and Transient psychotic disorder which also could be mistaken for schizophrenia. Both the above stated disorders have much better prognosis than schizophrenia.
My own experiences of over a long period of 50 years are more encouraging. About 25% of the patients treated for schizophrenia recover and stay well for long periods after recovery. Another 30% get short attacks at longer intervals but recover enough to return to their occupation and family life. Only about 20% do not recover adequately and have to be kept under psychiatric observation and treatment over a long period. They may not be fit to return to their family or society. About 10% of patients become chronically ill.
Recent addition of atypical antipsychotic drugs to psychiatrist’s repertoire has raised the hope of continuous and prolonged medication even for chronic patients without significant side effects. The demented schizophrenia patients seen by Kraepelin were desocialised, rejected or untreated patients of old style mental hospitals, when there were no antipsychotics at all. However he later did admit that 15% of all his patients recovered fully.
I have treated scores of chronic patients who later continued in their jobs till retirement, of course with the sympathetic help of colleagues and superiors. Some have helped their close relative to run small shops or trades over a long period.
One could compare schizophrenia patients with those of diabetes, hypertension, bronchial asthma, which also run a very long course in spite of regular treatment perhaps even for a lifetime. They are also not ‘curable’. Often such chronic physically ill persons are a burden to the family and perhaps to the society.
Yet they are not rejected like the persons afflicted with schizophrenia. The prejudice of the people is often based on superstitious beliefs that the person is possessed by evil spirits and should be avoided. Few of such prejudiced people realise that they can also act almost like the patients they reject when they lose control due to the influence of extreme joy or anger or under the effect of alcohol or a religious trance. In short, persons afflicted with schizophrenia under treatment are in no way much different from those who are physically ill over a long period. Their relatives must have hope of cure and show courage and determination to give their unfortunate relatives best chance for recovery and for returning to family life.
Diagnosis Of Schizophrenia
Dr. Vidyadhar Watve, MD, D PM FIRS
The term psychosis is used when a patient has delusions (false beliefs not shared by others), hallucinations (perceptions in absence of stimuli), disorganized speech, disorganized or catatonic behaviour (maintaining posture or sudden severe excitement).
Schizophrenia is one type of psychosis; but every psychosis is not schizophrenia.
Diagnosis :
Schizophrenia has four groups of symptoms.
1.Positive symptoms, which consist of delusions, hallucinations and disorganized behaviour.
2.Negative symptoms, which consist of emotional blunting, poor initiative, and poor communication.
3.Cognitive symptoms, which consist of poor attention, memory impairment, and poor planning.
4.Affective or emotional symptoms, which consist of anger, hostility, aggression, and depressive symptoms including suicidal ideation.
Schizophrenia consists of the presence of characteristic positive or negative symptoms of at least one month duration; deterioration in work, interpersonal relations, or self-care. These symptoms should not be due to general medical conditions, like brain tumor, encephalitis, malignancy or metabolic disorder.
Similarly, the above-mentioned clinical picture should not be due to substance dependence. Chronic alcohol dependence or cannabis dependence can produce a schizophrenia-like picture but such a case is diagnosed as substance-induced psychosis rather than schizophrenia.
If an illness otherwise meets the criteria but has a duration of at least one month but less than six months, it is termed as schizophreniform disorder. If it has lasted less than four weeks, it may be classified as brief psychotic disorder.
Schizophrenia can be diagnosed at any age if the criteria are met. Therefore the age-at-onset criterion is deleted from older classification of mental disorders.
Differential diagnosis
Schizophrenia remains a clinical diagnosis that is based on history and mental status examination (MSE). There are no pathological laboratory tests to diagnose schizophrenia.
After taking careful history from the relative, a compete physical examination is done to exclude psychoses with known medical causes. Similarly, substance-abuse as a cause of psychosis is also ruled out.
Psychotic symptoms have been found to result from substance – abuse (e.g. alcohol, cocaine, amphetamines, hallucinogens); intoxication due to commonly prescribed medications (e.g. steroids, anticholinergics, levodopa); infectious, metabolic and endocrine disorders; tumors and mass lesions; and temporal lobe epilepsy. Acute onset, clouding of the sensorium, or onset occurring after the age of 30 years requires careful investigation.
Routine lab tests are useful to rule out medical causes. They include CBC, urinalysis, L.FTs, BUN, TFT and serological tests for syphilis and HIV. In selected patients FEG, CT or MRI of brain will be useful.
The major task in differential diagnosis involves separating schizophrenia from schizoaffective disorder, mood disorder with psychotic features (mania or depression with psychotic features), delusional disorder, or a personality disorder. To rule out schizoaffective disorder and psychotic mood disorders, depressive or manic episodes should have been absent during the active phase and the mood episode should have been relatively brief as compared to the total duration of the psychotic episode. Delusional disorder has non-bizarre delusion which can be a delusion of infidelity or paranoid delusion or somatic delusion. The functioning in other areas is normal in delusional disorder. Schizophrenia is characterized by bizarre delusions and hallucinations.
Patients with personality disorders, particularly those in the eccentric’ cluster (e.g. Schizoid, schizotypal and paranoid personality), may be indifferent to sociail relationship, may have bizarre ideation and odd speech, or may be suspicious; but they do not have delusions, hallucinations, or grossly disorganized behaviour.
Patients with schizophrenia may develop other symptoms like thought disorders, behavioural disturbances and personality deterioration. These symptoms are uncharacteristic of the mood disorders, delusional disorder or the personality disorders.
Sometimes panic disorder is accompanied by feelings of unreality but insight is well preserved and there are no delusions or hallucinations. The rituals of behaviour occurring in a patient with obsessive-compulsive disorder may result in bizarre behaviour, but they are performed to relieve anxiety and not in response to delusional beliefs.
Thus diagnosis of schizophrenia needs careful history-taking, detailed clinical evaluation, and routine investigations to rule out other medical and psychiatric disorders which can mimic clinical picture of schizophrenia.
Treatment of Schizophrenia
Dr. Shailesh Chaugule, M.D.
Typical Antipsychotics Drugs:
The typical Neuroleptic (NLP) is still the drug of choice in schizophrenia even in the era of a typical NLP in certain cases with prominent positive symptoms. They are cheap as compared to atypical NLP.
Atypical Antipsychotic Drugs:
Antipsychotic drugs have revolutionised the therapies for people with schizophrenia. They have fewer side effects profile; they even remit many of the negative symptoms of schizophrenia; they also control many of the emotional and cognitive symptoms of this major psychiatric / brain disorder. Some of the major long–term side effects like tardive dyskinesia also appear to be less. Progressive research in this field is expected to further refine and sophisticate the therapeutic profile of these drugs.
Electro Convulsive Therapy (ETC) :
ECT stands for Electro–Convulsive Therapy. It is one of the most effective, rapidly acting, safe treatment modality in psychiatry. Unfortunately, it is unpopular, unacceptable among the general population, as it is also surrounded by various misconceptions. It is the wrong projection and unscientific presentation of electroconvulsive therapy i.e. shock’ treatment in Hindi movies that has led to a variety of misconceptions among people at large. The lack of efforts by psychiatrists to put forth the true scientific nature of treatment in various health awareness programmes has contributed to this persistent misunderstanding about ETC.
History/origin of ECT
It has originated from observations that patients suffering from epilepsy and psychosis become symptomatically better after occurrence of generalised – tonic – clonic seizure. Scientist thought that generalised seizure could be of therapeutic value in treating psychosis. In the period between 1934 and 1938 efforts to induce seizure using electrical stimulus were successful.
What is done during ECT?
In ECT the purpose is to induce generalised – tonic – clonic seizure in a patient. It is done in a very systematic and scientific way.
1.Fitness of the patient for general anesthesia is evaluated.
2.The patient is Nil By MoUth (NBM) for at least 6 hrs.
3.The patient is on a bed (and not in a chair as shown in the media).
4.Short acting general anaesthetic (GA) (Thiopentone – sodium) IV is given followed by muscle relaxant succinylcholine.
5.When the patient is under anesthesia and muscles are relaxed, electric current is passed through electrodes to induce a seizure. ECT machine is used to monitor duration and intensity of the current.
6.The patient gets the seizure but the jerky movements are very mild: muscle relaxant.
7. The patient sleeps for a variable period up to 1 hr. Since the patient is under anaesthesia, he does not have any memory of the procedure except for the prick of the needle.
Mechanism of action of ECT
Exact mechanism of action is not known. Various hypotheses have been put forth.
Indications for ECT
1.Severe depression, suicidal depression
2.Catatonic states
3.Excited aggressive psychotic patients
4.Patients who have not shown satisfactory response to various anti psychotics and anti depressants
Adverse effects of ECT
1.No permanent adverse effect of ECT is reported.
2.Short term memory lapses till the course of ECT is going on is common but memory lapses are short term and self–limiting.
Myths about ECT
1.It causes brain damage. In reality, no structural damage is reported so far.
2. Once ECT is given, it has to be given repeatedly throughout life. In reality, the course of ECT varies from 4 to 10 ECTs. Once recovery is achieved, there is no need for continuation of ECT.
3. After ECT, the patient becomes dull, listless, lethargic and sluggish. In reality, no such change is seen. Usually after ECT in Postictal state effect of concurrently administered medicine, the patient may feel drowsy for a while up to 30 minutes or so. But he/she never becomes dull and lethargic permanently.
Psychological Treatment of Schizophrenia
Dr. Shirisha Sathe,
Counselling – the popular name for psychotherapy – has a pivotal role to play in the recovery process of any kind of mental illness. And when the mental illness amounts to Schizophrenia, the recovery process turns out to be denser, primarily because of the multifold demands of the situation. And this in turn demands the role of psychotherapy to be more accommodating, cooperative and effective.
The role of psychotherapy in schizophrenia
The role of psychotherapy in schizophrenia as compared to its role in other mental illnesses is:
1.More expansive – as it has to transact with an array of issues ranging from personal to social.
2.More intensive – as the damage caused by the illness is severe in terms of physical and mental fitness, intra-personal and interpersonal relationships, and social and within family integration.
3.More subtle – as it is expected to deal with several delicate, sensitive and yet specific issues in the life of the sufferer which are closer to his heart and which may have an ever-lasting impact on the life of the sufferer and his/her closer circle.
The psychotherapist or the counsellor has to consider three objectives
1) Illness related objectives
a) Managing symptoms and impairment –
Though symptom management is primarily a domain of pharmacotherapy, when a patient experiences them, understanding those symptoms and coping with them to attain a good functional level is counsellors’ area. Being anxious about ‘what is happening to me?’, fearful about ‘Am I going crazy?’ depressed about ‘Do I have any future now?’ are some examples where the counsellor helps the person to manage the ‘problem’ out of the ‘problem’. Symptoms like disorganised thinking, hallucinations and delusions, cause considerable amount of problems in the day-to-day life of a patient. Only an expert psychotherapist is able to teach the patient to live with these symptoms by using psychotherapeutic tools and techniques and try to lead a normal life.
b) Preventing acute episodes and relapse –
To achieve this objective the counsellor has to be an educator not only to the patient but also to his/her caregiver. Illness, its causes, its nature, likelihood of relapse, role of medicine are various issues about which the patient and the family are normally ignorant. Along with early diagnosis, “relapse prevention” is a key factor in recovery process.
Recovery is an indefinite process in schizophrenia. So the patient and the caregivers need a long term planning about management of their internal and external resources. (Man, money, material, time, energy, etc.) The counsellor has also to discuss issues like the patient’s career, job, marriage in the context of the nature of illness. With the onset of the illness the bizarre behaviour damages the personal, interpersonal and social life of a patient and his family. Because of the stigma, the patient withdraws from the external world and the family withdraws socially. Here the counsellor’s job is to impart the skills like communication, self-disclosure etc. and help them rebuild the social support. Schizophrenia is an illness which places lots of demands on the family members. Right from understanding the illness, empathizing with the patient, being at the receiving end of his bizarre behavior and emotional outbursts, constantly worrying about the future, providing financial support and this too may be for an endless period of time. This affects the mental health and family dynamics on a large scale. Parent-child relation, sibling relation all are stressed and strained. To maintain the physical and mental health of the family members by facilitating healthy family interaction is the counsellor’s job. Social stigma, lack of self-acceptance, lack of acceptance of reality are the major blocks in reducing a handicap. Counsellor has to help the patient and the family to overcome his block so that the person can regain a grip on his career and meaningful productive life in spite of the limitations put by the illness. Taking “continuous efforts” for getting well is a prime requirement and responsibility of a sufferer but maintaining his or her motivational level is a big task for the counsellor as the process of recovery is tough, exhaustive and many a times frustrating for the patient. Many acquired skills, e.g., social skills like communication, emotional skills like expressiveness, assertiveness, thinking skills like goal setting, problem solving etc. are lost with the progressing illness. Sometimes even the self-care skills are lost. The patient has not only to relearn these skills but he also needs a special training in using these skills in a variety of situations and conditions. familial support, liaison and cooperation amongst other helping agencies, influencing social policy towards preventive ways – are some of the various issues which a counsellor has to tackle with the help of other support systems from self-help support groups to even the professionals from the field of law. Thus the counsellor, as an expert, empowers the patient and the caregivers and, as a responsible human being, creates awareness in the society so that non-threatening, accepting and accommodative surrounding, conducive to recovery of the patient afflicted with schizophrenia, prevails.c) Long term management and planning –
2) Identifying and managing stressors
a) Fostering social and interpersonal reintegration –
b) Managing family and carer symptomatology –
c) Reducing the handicap –
3) Other objectives
a) Enhancing self help –
b) Generalisation of skills –
c) Mobilising extra-