Schizophrenia is a form of psychosis where sufferers cannot distinguish their own thoughts and ideas from reality.

SCHIZOPHRENIA is a chronic mental health condition with a variety of symptoms. The word is derived from the Greek words “skhizein”, ie “to split”, and “phren”, ie mind. However, it does not mean that a sufferer with the condition has a “split mind”.

It is classified as a psychosis – the sufferers cannot distinguish their own thoughts and ideas from reality. Patients with schizophrenia are unable to think logically, and have difficulty in differentiating between real and unreal experiences.

The National Mental Health Registry 2003-2005 recorded 7,351 schizophrenia cases, of which 3,714 (50.5%) were new cases. The incidence rate from this report is about five cases per 100,000 population per year, whereas the expected cases are about 100 cases per 100,000 population per year. Two thirds of the patients were between 20 and 40 years old, and 23% had a family history of the condition, while about 20% had another condition, with substance abuse being the commonest (about 80%).

Drug abuse or misuse increases the risk of schizophrenia, and may also precipitate the condition. The drugs include cannabis, cocaine and amphetamines.

Childhood-onset schizophrenia is rare, but if it occurs, there may be difficulty in distinguishing it from developmental disorders like autism.

There are misconceptions about schizophrenia because it is often not well understood by the public. It is not the same as “multiple personality disorder” or “split personality”. On the other hand, schizophrenic patients have a mind that is dysfunctional and disordered.

Although there are many studies that report a link between violence and schizophrenia, violent acts by schizophrenics are rare. Violence is more likely to be associated with substance abuse or misuse or alcohol. The schizophrenic is much more likely to be a victim of violence rather than be the perpetrator.

Cause unknown

It is not known for certain what causes schizophrenia. It is believed an interaction of genetic and environmental factors causes the condition. Some people may have some risk factors that increase their likelihood of developing the condition, which is then precipitated by a stressful or emotional life event. It is not understood why some people with risk factors develop the condition while others do not.

The risk factors include:

·Genetics

Schizophrenia is more common in families, but there is no single gene responsible. If one identical twin has schizophrenia, the other twin has a one in two chance of having the condition. If one non-identical twin, who has only half of the other twin’s genetic make-up, has schizophrenia, the other twin has a one in seven chance of having the condition.

This compares with a one in 100 chance of having the condition in the general population.

·Brain

There are differences in the brain structure and/or the distribution or number of brain cells in schizophrenics. However, these changes are not found in all schizophrenics, and they are also found in people who have no mental conditions.

There are studies which suggest that schizophrenia may be due to an imbalance between dopamine and serotonin, which are neurotransmitters, ie chemicals that pass messages between brain cells. Other studies suggest that schizophrenia may be due to an altered sensitivity to the neurotransmitters.

·Infections

There is some evidence that the polio and influenza viruses may play a causative role.

·Pregnancy and childbirth

Certain pregnancy and childbirth conditions may increase the risk. They include bleeding, gestational diabetes, pregnancy induced hypertension, intra-uterine viral infection, growth retardation, and birth asphyxia.

·Head injury

Traumatic head injury increases the risk, but the mechanism is unknown.

There are some known precipitating factors, which include:

·Stress

The usual precipitating factors are stressful or emotional life events, eg loss of job, end of a relationship, bereavement, or abuse. These factors do not cause schizophrenia by themselves but does so in a person who has risk factors.

·Drug abuse

Drug abuse or misuse increases the risk and may also precipitate the condition. The drugs include cannabis, cocaine and amphetamines.

Clinical features

The clinical features usually develop slowly over months or years. There may be occasions when there are many symptoms, while there are few or no symptoms on other occasions.

The initial symptoms of increased irritability or tenseness, difficulty sleeping and/or difficulty concentrating may be difficult to identify. As these symptoms often develop during adolescence, they may be attributed to “normal” adolescent behaviour and ignored.

The initial symptoms often appear several years before the first acute schizophrenic episode (prodromal period). They usually begin gradually and then worsen slowly. The patient becomes more withdrawn and exhibits an increasing lack of care about personal appearance and hygiene. There is loss of interest in relationships, sex, and life activities. This often leads to relationship problems with family and friends.

As the condition develops, changes in thoughts or behaviour develop. They include:

·Hallucinations occur when the patient experiences a sensation which does not exist. It can involve any of the senses, but hearing voices are the most frequent. Brain scans have demonstrated changes in the speech area of schizophrenics when they hear voices, indicating that their experience is real, ie their brain mistakes thoughts for real voices. The voices heard are usually critical, abusive or annoying, but some report pleasant voices.

·Delusions are strongly held beliefs that are not based on reality. They may occur suddenly or gradually develop over weeks or months.

·Changes in thoughts. Some schizophrenics experience difficulty in concentrating and drift between unrelated topics (loose associations). Others feel that their thoughts are controlled by someone else, their thoughts are not their own, or their thoughts are being “removed” and that someone else is controlling their mind.

·Changes in behaviour. The schizophrenic’s behaviour may become unpredictable or even bizarre. There may be inappropriate behaviour or extreme agitation, with shouting and swearing for no reason.

The clinical features may vary, depending on the type of schizophrenia:

·Paranoid schizophrenics have false beliefs that others are trying to harm them or their loved ones and may be anxious, angry, argumentative, or aggressive.

·Catatonic schizophrenics are inactive with minimal or no response to other people. Their posture and muscles may be rigid, with odd facial grimaces.

·Disorganised schizophrenics have confused thoughts and problems expressing ideas. They show little emotion (flat affect), are apathetic, and exhibit child-like behaviour.

·Undifferentiated schizophrenic may have clinical features of more than one type.

There is no single diagnostic criterion for schizophrenia. It is usually diagnosed if:

·There are at least two of the following, ie hallucinations, delusions, changes in thoughts or behaviour, or features like flat affect;

·The features have been present for more than six months;

·There is significant impact on studies, work or activities of daily living;

·Other possible conditions like depression, bipolar disorder, or drug abuse or misuse have been excluded.

When a family doctor suspects a patient has schizophrenia, a referral will usually be made to a specialist. As the person with suspected schizophrenia may be reluctant to consult a doctor, it may be necessary for a family member or friend to persuade the person to do so.

If the acute schizophrenic episode is worsening, the patient may have to be taken to the accident and emergency (A&E) department of a hospital. If it is severe, the psychiatrist may request for compulsory detention in the hospital for assessment and treatment under the Mental Health Ordinance.

Managing schizophrenia

There are various guidelines regarding the quality of care for schizophrenia. The National Institute for Health and Clinical Excellence (NICE) of the United Kingdom recommends that anyone providing treatment and care for people with schizophrenia should:

·Develop a supportive relationship with patients and their carers;

·Explain causes and treatment options to everyone, keep clinical language to a minimum, and provide written information at every stage of the process;

·Enable easy access to assessment and treatment as soon as possible through all stages of care; schizophrenics receive an assessment by a multidisciplinary team and are routinely monitored for other conditions;

·Work with patients, and their families and carers, if they agree, to write advance statements about their mental and physical healthcare, especially if they have severe episodes or have been treated under the Mental Health Act (these should be included in the care plans);

·Take into account the needs of the patient’s family or carers, including physical, social and mental needs, provide information about schizophrenia, and how families and carers can help, and offer a carers’ assessment; and

·Encourage patients and their families and carers to join self-help and support groups.

The availability of newer antipsychotic medications in the past two decades have, in the opinion of most psychiatrists, revolutionised the treatment of schizophrenia. These medications are effective in treating all the symptoms equally well and the incidence and severity of side effects are less.

Schizophrenics and their carers can manage the condition better by:

·Being able to spot the signs of an acute episode.

·Taking the medicines as directed.

·Avoiding drugs and alcohol.

·Regular attendance at clinic appointments.

·Taking responsibility for self-care.

Source: Dr Milton Lum

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