Schizophrenia is a disorder of the mind – it changes how we think, feel and as a result how we behave. The symptoms vary for each individual but tend to fall into two categories, positive and negative. The mind may change in someone with Schizophrenia – experiencing and interpreting life in a way that is different to other people.
These are the unusual experiences that can be intense and troubling to friends and family. These include hallucinations – feeling or being aware of a sensation that isn’t really there. This may include hearing, feeling, smelling or seeing something that no-one else experiences. The most common hallucination is hearing voices.
The difficulty of these hallucinations is that the sensation or smell or voice seems utterly real and it becomes impossible to distinguish reality from a hallucination, which can be enormously distressing. Sometimes the voices may be critical, abusive or attacking or can instruct the person to do unwise things. It may be the person’s own voice in their head, the voice of someone else, or as if people are talking about them in a group conversation.
It is unhelpful to consider that these voices are imagined. They are real and the person experiencing psychosis does hear them. Yet they are from their own mind rather than from any external source. Brain scans show that the voices that patients hear are coming from their own mind as the speech and language areas of the brain light up, but yet the body recognizes the voices as being external.
Not everyone that experiences voices or a similar delusion is necessarily experiencing schizophrenia, in some cases of severe depression people may experience repeating words or phrases that are negative and self-critical.
Voices are not the only kind of hallucination and some may present with symptoms that are much more visual or tactile. Some may see objects moving in front of their eyes or see people that aren’t really there. Some may feel others touch their skin or shake their hand when really no-one is there 8.
The second key positive symptom is a delusion – this is a false perception – when you believe something but in reality you have misunderstood what it happening. The way you see and interpret information around you is different from everybody else. The individual may present an idea or a set of ideas but be unable to explain them from their culture, background or religion. It is as if their interpreting system is different to everyone around them and a particular sensory input provokes a different output response. Their beliefs are often considered to be strange or unrealistic but to them they make complete sense 10.
The onset of these symptoms may be rapid and occur over the course of a few days or weeks – often a person may feel a little unwell or confused, generally not themselves and then develop these symptoms which they may feel are an improved clarity in themselves- these voices and delusions appear to give them an increased clarity in their own mind but to others are confusing, distressing and difficult to understand.
Paranoid delusions are especially distressing – these may involve the feelings of persecution, for example from a neighbour or from the government. They may be everyday paranoid feelings such as conviction that a partner is being unfaithful or that your dog is really a person.
Ideas of reference describe interpreting special meanings to ordinary day-to-day events. It almost feels as though you have special connections with the radio, the TV or a person that walks past you in the street. Colours, animals or objects develop special importance or significance that no-one else shares.
Thought disorder makes it difficult to focus and concentrate on one thing. It is hard to stick to one idea and your mind may drift between seemingly unconnected ideas. This can be accompanies by ideas that thoughts have suddenly disappeared or thoughts that are not your own have been inserted into you mind, as if someone else’s consciousness has been inserted into your mind. This may be to the extent that your body feels taken over and controlled by something or someone else 11.
The most important symptoms for prognosis are not the positive symptoms that have been discussed above but instead are the negative symptoms. These are often the symptoms that the publics are less aware of- they are less outrageous and shocking and thus receive less media and public attention.
Despite this they should be of high concern and importance as they are the greatest predictors of outcome. Negative symptoms resemble those of depression – they include a loss of interest in previously enjoyable activities, an inability to concentrate, a lack of self-maintenance, feelings of unease around others and a loss of normal thoughts, feelings and motivations. Energy and emotions seem to melt away- leaving the individual unable to feel very excited or enthusiastic about anything.
Importantly it should be remembered that not everyone with schizophrenia experiences all of these symptoms or at least not all of them equally. For those with continuing schizophrenia about 1 in 7 will become depressed. For 50-60% of those who are experiencing schizophrenia for the first time their first symptoms will be those of depression and lowness 12.
Figure 1: the three categories of schizophrenia signs and symptoms
How might a person with Schizophrenia present?
It depends, during the early stages they may present feeling unwell and saying they are hearing voices, others in more severe stages may present with an overriding severe depression. The balance between positive and negative symptoms varies, as does the specific nature of the symptoms.
Most symptoms can be placed in some kind of context- someone who is very religious is more likely to have religious delusions about god or a calling and someone who has recently suffered bereavement is more likely to have delusions or hallucinations about the deceased person 13.
Schizophrenia affects around 1 in 100 people over the course of their lives. It affects men and women equally- but men tend to present at a slightly younger age. The peak incidence is those in their early-mid twenties 14.
Figure 2: a diagram showing that, with 1 in 100 people affected, schizophrenia is much more prevalent than many think
The etiology (cause) of Schizophrenia is poorly understood. It may be a combination or genetics and environment.
For the 1 in 100 that get schizophrenia 1 in 10 will have a parent who has or had schizophrenia. For identical twins there is a 1 in 2 chance that if one twin has the illness the other will too. Non-identical twins have a 1 in 8 chance of developing Schizophrenia. The genetic link for schizophrenia is one of the strongest for any mental illness, having stronger genetic associations than addiction, Alzheimer’s, anxiety or bipolar 15.
Figure 3: an explanation of the main genetic statistics of schizophrenia
Aside from genetic susceptibility there are other contributing factors. Brain scans show that problems at birth such as a lack of oxygen to the baby’s brain or a viral infection during pregnancy can be risk factors.
One of the strongest environmental risk factors is heavy Cannabis consumption, which increases the risk two fold. For those that start using Cannabis in their early teens they are most at risk.
Stress is an important trigger and can worsen mild symptoms or trigger a psychotic episode. Highly stressful situations like a road traffic accident or bereavement or even long term everyday stresses can contribute.
Difficulties in childhood such as abuse or deprivation increase the likelihood of a cluster of mental illnesses. These childhood difficulties are also associated with stress and increased likelihood of drug use, which are all interlinked with risk of developing schizophrenia 16.
Figure 4: the four main environmental risk factors of schizophrenia
Schizophrenia or any other type of psychosis affects people differently. Some may not see it is a negative – consider the comfort it may bring to hear the voice of a loved one after their death; other’s believe they have super-powers or incredible abilities and maybe this seems exciting and exhilarating. This said for many having schizophrenia bring anxiety, confusion, fear, distrust and resultant isolation. People often describe feeling victimized and threatened.
The illness may affect the ability to look after yourself and to carry out day-to-day activities with ease. Often family or work friends notice a change or an inability to cope, which is the initial reason why the patient presents. Concentration can be a challenge and focusing for any long period becomes almost impossible. Trusting others and maintaining relationships becomes difficult as our impression of reality becomes different to those around us.
As well as this often patients face stigma and fear that others will view them as aggressive or dangerous. Voices or delusions may tell patients to harm themselves or feeding them critical comments, which can be extremely difficult to cope with 17.
Perhaps consider that many do cope and overcome schizophrenia – take John Nash for example who won the Noble Prize in 1994 for his work on the ‘Game Theory’ and whose life story formed the basis of the film a beautiful mind 18.
The first step is for the patient to visit their GP; they will be referred to their local psychiatric services for assessment, treatment and care. NICE (the National Institute of Health and Care Excellence) recommends a combination of both antipsychotic medications and talking treatments 19.
Talking treatment give patients an opportunity to talk about difficult feelings or situations with a trained professional. Cognitive Behavioral therapy (CBT) is a popular form of talking therapy. This aims to link thoughts to feelings and consequent behavior and aims to develop practical skills for the patients to help themselves and to get out of negative patterns of thought and behavior. This can be developing coping strategies for hallucinations or delusions, methods for coping with stress or managing the side effects of medication or comorbid anxiety and depression. Despite its benefits CBT often has a long NHS waiting list.
Family intervention therapy can be helpful – developing improved communication and problem solving skills for patients. The entire family will be involved and will develop skills for sharing tasks, for talking and for developing skills together. Counseling – which is supportive listening and social skills training can be helpful too 6.
Antipsychotics are the groups of medications that are prescribed. These are targeted at the positive symptoms of schizophrenia. These are often beneficial to patients but can have some distressing side effects like weight gain and mental slowness. Often patients may need to try different types of antipsychotics before finding the one they find the one they are best suited to 20.
Antipsychotics are for psychosis – this may be on off or long term as part of an illness like schizophrenia. Some of the older antipsychotics caused side effects like rashes, sedation or changes in heart rhythms, muscle spasms etc. The newer antipsychotics have major side effects of weight gain and metabolic effects- other side effects are extreme sleepiness, dizziness or low blood pressure when standing up. Some very serious long-term use side effects exist but these are very rare 20.
Prognosis is an educated guess of the long-term outlook for a patient with a particular illness. Schizophrenia is a diverse disease and can be crippling for some, inconvenient for others and some may fully recover from an episode and go on to lead a schizophrenia-free life. It is extremely difficult to predict. The overall prognosis is that 1 in 5 will get better within 5 years, 3 in 5 will get better but may relapse and 1 in 5 will have difficult symptoms for a prolonged period 5.
We cannot prevent mental illness entirely, but we can consider the triggers and advice on avoiding these. This is especially important for those that are genetically at highest risk of illness. Avoiding highly stressful events wherever possible, or far more realistically, creating a society that supports those in high stress, to aid their recovery and well-being are important.
As a doctor you will not just consider how to treat those that present in your clinic but also about how on a larger scale we can improve the health of society- perhaps by lobbying for better support systems for those who are socially isolated, who are abused, homeless of living in poverty, so as to reduce the risk of mental illness. Encouraging against drug abuse is also critical. Cannabis, cocaine and other amphetamines are key culprits in contributing to schizophrenia risk. These drugs can also limit the efficacy of treatments so are important behaviors to tackle.
When thinking about prevention think about risk factors. There is some evidence that living in a city may increase the risk, being African-Caribbean seems to also increase your risk and important events like migration, cultural differences or even viruses or allergic reactions may be triggers too. Some of the risk factors we can potentially prevent or reduce with more research but some like race or genetics are not factors we can adjust so instead we should be aware of who is higher risk and consider if we should target them with preventative medical advice 21.
Why should we care about mental illness?
We cannot afford not to. The mental health charity Mind reports that there is more misguided information about schizophrenia that any other type of mental illness. Three key misconceptions are that those with Schizophrenia have a split personality- i.e. they swing from being very calm to being out-of-control, that those diagnosed are dangerous and more likely to commit crimes and lastly that those who hear voices are dangerous.
1 in 4 experience a mental health problem every year. The more we talk, the more we understand the easier it will be to help those who are suffering. The more open dialogues about mental health, the greater the acceptance and support for those who need it. Fear can often stem from a lack of knowledge and so as future medical students it is important to act as role models by being educated about important issues and being open to discussing issues so as to relieve stigma.
This is especially critical because of the huge burden of psychosis- suicide rates in those affected are 10% and carers and families are highly affected too; some may sacrifice their careers to care for a family member and others may suffer anxiety or depression. Despite this much progress is being made – both to support those with disease and their families. Huge progress has been made over the last century with regards to mental health but there is still room for further education and acceptance among the public 22.
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