Schizophrenia. Symptoms, Diagnosis, and Treatment

Schizophrenia. Introduction

Schizophrenia is a serious mental disorder characterized by profound impairments in thinking and feeling. In most patients, especially those untreated, schizophrenia develops progressively. The end stage of such dynamics is the residual schizophrenia characterized by major personality changes and patient’s invalidism.

There are diverse types of schizophrenia with varying impact on the patient’s thinking content, feelings, and behaviours. The most common symptoms of schizophrenia are delusional thinking, hallucination, emotional indifference, and social withdrawal.

Psychosis and schizophrenia

The term psychosis refers to various mental disorders characterized by changes in thinking, feelings and people’s perceptions of themselves and the world around them. Schizophrenia is the most common disorder within the wider group of psychosis.

Schizophrenia affects people from all walks of life. The most frequent onset of schizophrenia happens in younger people age between 15 and 30, both men and women alike.

Etymology and terminology

The word “schizophrenia” comes from the Greek roots “schizo” = division and “phrene” = spirit describing the fragmented thinking of people with this disorder.

The term “schizophrenia” was coined by Swiss psychiatrist Eugen Bleuler. Despite the term’s meaning, schizophrenia does not imply “split mind”. In public opinion schizophrenia is frequently confused with the dissociative identity disorder, also known as “multiple personality disorder” or “split personality disorder”, a rare psychiatric condition.

Signs and symptoms

Psychiatrists characterize the symptoms of schizophrenia as “positive” or “negative.”

Symptoms caused by the disease (eg, hallucinations, delusions) are labeled “positive.”

“Negative” refers to traits that have been lost through illness (e.g. drive and motivation have disappeared).

In most cases, the patient does not admit that he is ill (denial) and refuses to seek professional help.

Symptoms may include the following:

Jumbled thinking

People with schizophrenia may have trouble getting their thoughts straight. This often means that a person says things which don’t make sense to others.

Disorganized thinking and speech

Such disorganization may range from loss of train of thoughts, to loosely connected sentences up to the full incoherence known as “word salad”.

False unshakable beliefs

Paranoia (beliefs of persecution): the person may believe that others are trying to harm him.

Ideas of grandeur

Patient believes that he has strange powers or is omnipotent.

Altered sense of self

The person has a strange perception of his body; he may feel his arms and legs, or other parts of his body do not belong to him or are altered. Sometimes he feels like he is bodiless, non-existent as a person. He finds it difficult to distinguish between where his body stops, and the rest of the world begins.

Thoughts broadcasting

patient is convinced that others can hear his thoughts or that the TV or radio is sending him special messages.

Hallucinations

Most frequent are auditory hallucinations such as hearing voices.

Changes in emotions

Emotions may get dull and flat, or out of control and over-excited. Flattened emotions may result in a lack of facial expression and in inability to maintain normal social interaction. The emotions may also be incongruent to the situation, for example, laughing by some sad news or crying at something funny.

Loss of purpose

The person feels drained of energy and drive losing interest in life. The progression of the illness causes the neglect of his health and personal hygiene.

Social withdrawal

The person retreats from the world, avoids the company of others, isolates himself losing social skills and not being able to survive on his own in his society.

Most people with schizophrenia do not have all these symptoms. Some are more severely affected by them than others.

How does schizophrenia develop?

Any human thought, perception, and reaction, including the appropriate evaluation of others’ behaviour and the ability to establish trusting contacts are the products of complex brain functions.

The undisturbed chemical balance of neurotransmitters in the brain ensures the proper processing of environmental stimuli and inner psychological thought circuits. This forms the basis of attention, organized thinking, and purposeful actions.

Symptoms of schizophrenia are caused by the disturbance of various metabolic processes in the nerve cells in different brain regions. Particularly, the regulation of the dopamine neurotransmitter system is affected, as well as that of the glutamatergic or GABAergic excitatory transmission.

Remarkably, schizophrenia is also linked causally to genes that control the early developmental organ formation of the brain and ensure the formation of neural networks.

Causes of schizophrenia

There are several assumptions about why the neurotransmitters involved in the central nervous system become imbalanced. However, no-one knows yet what causes schizophrenia. The most plausible explanation is the multifactorial origin of schizophrenia. Genetics, early environment, neurobiology, and psychological and social processes appear to be important contributory factors.

Genetics

Historically, Kraepelin and Bleuler, the pioneers in the identification and treatment of schizophrenia were in favour of the hereditary cause of schizophrenia. Bleuler wrote: “Schizophrenia appears to be independent of external conditions and circumstances.”

Kraepelin also emphasized the genetic (inheritance) factor but added as a possible cause physical illnesses in childhood, such as brain inflammation.

Vulnerability to schizophrenia is partly inherited, with no single gene responsible for the condition. The illness is more likely to occur in those with a schizophrenic first degree relative in the general population. Nevertheless, the majority of individuals with a close blood relative with schizophrenia do not develop the illness themselves. And schizophrenia commonly occurs in families where no-one is known to have had the illness before.

Birth complications or infectious diseases of the nervous system are also discussed as causes of schizophrenia.

Neurobiology

Current research is focused on the role of neurobiology. There are billions of nerve cells in the brain. Each nerve cell has branches which transmits and receive messages from other nerve cells. The branches release chemicals, called neurotransmitters, which carry the message from the end of one nerve branch to the end of another. In the brain afflicted with schizophrenia, something goes wrong in this communication system. The evidence that schizophrenia is a biologically based disease of the brain has accumulated rapidly during the past two decades. Recently this evidence has also been supported with dynamic brain imaging systems. This images precisely show the wave of tissue destruction that takes place in the brain of the sufferers.

Environmental factors

Recently research proved the role of environmental factors in the onset of schizophrenia. Several studies have examined the relationship between experience of a stressful event during pregnancy, and later psychosis. The conclusion was that risk of schizophrenia is increased among children of mothers who were exposed to sudden disasters during the pregnancy.

Also, stressful events in the childhood, such as broken homes, or child abuse, correlate with a higher risk for schizophrenia. Such events are seen as triggering factors for schizophrenia in vulnerable individuals. They have also modifying (aggravating) effect of the course of the illness once evolved.

Early and regular use of psychoactive substances such as THC, methamphetamine, opiates, and hallucinogenic drugs increases the risk for psychosis.

An increased prevalence of psychosis in urban compared to rural settings is one of the recent consistent findings in schizophrenia research. In a recent follow-up study of the entire Swedish population, those living in the urban areas had around 70% higher risk of developing schizophrenia compared to the rural population.  

Also, social isolation and social disadvantage, such as low social class, reduced access to health care, lack of social support, unemployment, and poor physical health, correlate with increasing the risk for schizophrenia.

Types of schizophrenia

Since Bleuler’s time, the definition of schizophrenia has continued to change. The main achievement was the more accurate differentiation of the different types of schizophrenia. Without knowing the exact causes of schizophrenia, the classification is based on the appearance of symptoms occurring together. The ICD 10 and DSM-V classification is not helpful in predicting outcome of the disorder.

The classification in accordance with ICD 10, a diagnostic system of World Health Organization (WHO), distinguished the following types of schizophrenia

Paranoid Schizophrenia

It is the most common type of schizophrenia in most parts of the world. The clinical picture is dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory variety, and perceptual disturbances.

Hebephrenic or disorganized Schizophrenia

In hebephrenia, also called disorganized schizophrenia, the predominant symptoms are affective changes, followed by fragmentary delusions and hallucinations, erratic behaviour, and mannerisms. The mood is shallow and inappropriate and often accompanied by giggling or self-absorbed smiling, or by a lofty manner, grimaces, mannerisms, pranks, hypochondriacal complaints, and reiterated phrases. Thought is disorganized and speech rambling and incoherent. There is a tendency to remain solitary, and behaviours seem empty of purpose and feeling. This form of schizophrenia usually starts between the ages of 15 and 25 years and tends to have a poor prognosis because of the rapid development of “negative” symptoms, particularly the flattening of affect and loss of volition.

Catatonic Schizophrenia

This type of schizophrenia became extremely uncommon in the western countries. Catatonic schizophrenia is characterized by psychomotor disturbances which may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods. Episodes of violent excitement may be a striking feature of the condition. For reasons that are poorly understood, catatonic schizophrenia is now rarely seen in industrial countries, though it remains common elsewhere. These catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic hallucinations.

Schizophrenia simplex (Simple Schizophrenia)

Schizophrenia simplex is less common type of schizophrenia but still can be seen in industrialized countries. In simple schizophrenia, there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and a decline in total performance. Delusions and hallucinations are not common. The disorder is less obviously psychotic than the hebephrenic, paranoid, and catatonic subtypes. The schizophrenia simplex unfolds gradually without or less prominent psychotic symptoms, such as delusions and hallucinations. The course of schizophrenia simplex can be compared to a “silent implosion” of the person’s personality, characteristic by “negative” symptoms (e.g. blunting of affect, loss of volition). With increasing social impoverishment, vagrancy may ensue, and the individual may then become self-absorbed, idle, and aimless. Schizophrenia simplex evolves gradually into residual schizophrenia.

Residual Schizophrenia

This type is a chronic stage in the development of a schizophrenia. It is the end stage of an auto-destructive brain process which happens on the neurobiological level and leads to permanent changes of the brai structure. On the psychological level it’s characterized by the “negative” symptoms combined with severe intellectual and emotional impairment and progressing invalidism.

Treatment and prophylaxis

To achieve the best results in the treatment of schizophrenia is to provide the proper care to the patient. This implies an early recognition and treatment at the earliest stage of the disorder.

A vital role in the treatment of schizophrenia is the use of medication called anti-psychotics. Using this medication, the symptoms of schizophrenia can be suppressed, ideally even fully eradicated.

The prerequisite of an effective treatment is a close psychiatric monitoring and the use of the psychotherapy. Other key roles ply the socio-therapy by involving a social worker as well as the education and integration of the family in the treatment process. The next step is the patient’s integration into the society for example trough protected work environment and/or patient’s professional education helping him to find a suitable occupation and getting financial independence.

Prophylaxis includes training of the primary health care personnel allowing the recognition of the early signs of schizophrenia. The other measure is providing public education to decrease stigma and discrimination of people with mental health disorders.

Schizophrenia in facts

• Schizophrenia affects about 24 million people worldwide
• It is a treatable disorder. There are effective interventions (pharmacological and psychosocial) available.
• The earlier the treatment is initiated, the more effective it will be.
• More than 50% of persons with schizophrenia are not receiving appropriate care
• 90% of people with untreated schizophrenia are in developing countries
• Care of persons with schizophrenia can be provided at community level, with active family and community involvement

Famous people diagnosed with schizophrenia

A recent Nobel Laureate in Economics, John Forbes Nash Jr., has a lifetime history of Schizophrenia. His biography has been documented in the book “A Beautiful Mind” and the academy award-winning movie of the same name.

Following is a list of other famous people who have been diagnosed with schizophrenia, or who had suffered from schizophrenia:

Albert Einstein`s son – Eduard Einstein

Dr. James Watson`s son (Dr. Watson who co-discovered the structure of DNA and Nobel Prize winner)

Peter Green, Guitarist for the band Fleetwood Mac

Syd Barrett of the band Pink Floyd

Mary Todd Lincoln, wife of Abraham Lincoln (past-President of the United States)