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34
SCHIZOPHRENIA
Incidence
Schizophrenia is found world-wide, with an almost uniform distribution in
various countries and cultures. About 1% of the general population suffers from
schizophrenia or, in other words, about 10 people out of every 1000 are likely to
develop schizophrenia at some time in their lives. The disorder usually begins in late
adolescence or early twenties, though it can develop at any age. Males and females
are equally affected.
Aetiology
Aetiology of schizophrenia still eludes precision and remains one of psychiatry's
greatest challenges. No single factor has been found to cause schizophrenia and the
aetiology is perhaps multifactorial. The following theories have been put forward.
Genetics
While genetic predisposition to schizophrenia is quite well known, the nature of
its transmission is still unclear. However, different studies have proposed polygenic
inheritance with partial penetrance. Representative figures for concordance are about
50% for monozygotic (MZ) pairs and 17% for dizygotic (DZ) pairs. Approximate
life time expectancy of developing schizophrenia for relatives of patients suffering
from schizophrenia* is given below:
35 UNDERSTANDING PSYCHIATRY
Parents 6%
Siblings 10%
Children (one parent schizophrenic) 14%
Children (both parents schizophrenic) 45%
Adapted from Shields (1980)
Biochemistry
(a) Dopamine hypothesis: This is, by far, the most widely accepted hypothesis,
which could explain the positive symptoms in acute schizophrenia. The
hypothesis states that in the meso-limbic system of the brain, there is an excess
of dopaminergic activity which could be due to excess of dopamine, deficiency
of dopamine antagonists or increased sensitivity of dopamine receptors.
(d) Glutamate hypothesis: It proposes that glutamate and glutamate receptor genes
are involved in neuro- development and that abnormalities in these systems lead
to neuro-developmental schizophrenia.
(f) Virus-like agents: These have been isolated from the CSF of some schizophrenic
patients. Moreover, winter births are more common in schizophrenic patients
than in the general population. Prenatal viral infections, e.g. influenza, during
the winter months, may be responsible for this increased frequency.
(g) Monoamine oxidase hypothesis: Murphy and Wyatt (1972) reported reduced
levels of monoamine oxidase (MAO) in the platelets of schizophrenic patients.
This finding was later replicated by other workers like Belmaker (1976). Some
other workers could not replicate the same finding. However, it was found that
SCHIZOPHRENIA 36
some non-schizophrenic disorders also had lower MAO levels suggesting that
low MAO activity may predispose to schizophrenic illnesses.
(c) Studies about life events and expressed emotion, starting in 1960s (Brown,
Birley) and continuing presently (Leff 1992), found that relapses in
schizophrenic patients may be preceded by increased life events. They are also
increased in families with high expressed emotions, e.g. with features of
hostility, critical comments and emotional over-involvement.
Social processes
It has been shown that patients suffering from schizophrenia are over
represented in disadvantaged areas of community. Some workers have reported high
rates of schizophrenia amongst migrant population. Schizophrenic patients are also
known to be living alone, unmarried and with few friends. The disorder becomes
more prevalent as one goes down the social scale. Two different hypotheses have
been put forward in this regard: drift hypothesis and breeder hypothesis. The first
implies that a person suffering from schizophrenia drifts down the social scale
because of his illness while the second hypothesis postulates that the lower social
stratum breeds the illness as it is more prone to stresses because of natural reasons.
The first hypothesis is now largely accepted.
Psychological theories
(a) The 'sensory filter', which limits the amount of sensory information reaching
consciousness, is supposedly defective in schizophrenic patients and as a result,
they are over stimulated by their environment and cannot channelise their
attention properly.
Neurological abnormalities
Neurological abnormalities like non-localizing (soft) neurological signs,
thickening of corpus callosum, ventricular enlargement in chronic schizophrenic
patients beside widening of sulci and atrophy of the cerebellar vermis and EEG
abnormalities like decreased alpha activity, increased theta and delta activity, fast
activity, paroxysmal activity and specific activity have been reported by different
workers.
Constitutional factors
Some workers have pointed out that factors like asthenic body, schizoid type of
personality, higher birth orders or first born and birth complications have something
to do with the genesis of schizophrenia in certain patients.
Precipitating factors
Certain events like child birth, physical illness, viral infections and psychosocial
stresses have been reported to precipitate schizophrenia. Interpersonal, social and
cultural factors have been postulated to influence the course of schizophrenia.
Neurodevelopment theories
These theories propose that a combination of genetic and environmental factors
leads to defective development and maturation of the brain which, later, leads to the
development of schizophrenic illness. Retrospective studies of schizophrenic patients
report more obstetric complications than do studies of normal controls. The more
recent studies, however, have not found a consistent relation. It has been suggested
that such positive associations between obstetric complications and schizophrenia
may be confined to males or that birth injury may corelate with other aspects of the
disorder such as early age of onset. These notions are consistent with recent research
findings, e.g. enlargement of cerebral ventricular size antedates the development of
schizophrenia and is not progressive in the majority of cases; boys who develop
schizophrenia have shown more abnormalities in their premorbid personality, social
adjustment and intelligence levels as compared to their peers; structural
abnormalities of the brain in schizophrenia, especially a reduction in temporal lobe
and hippocampal size, are not associated with gliosis, which would normally be
expected if a degenerative process was at work.
Clinical features
Many different clinical pictures may occur in schizophrenia and the onset of
illness may be acute or insidious, leading to a gradual deterioration of personality in
many cases.
Thought disorders render the patient's conversation unintelligible and the use of
neologisms or newly invented words by the patient renders the speech nothing more
than a word salad and can hardly be understood.
Disorders of emotion
Incongruity of affect, i.e. the expression of an emotion not appropriate to the
occasion, is sometimes very marked in a schizophrenic patient. Emotions and
feelings become blunted and the individual appears insensitive. During the early
stage, depression is common but there may be sudden outbursts of panic or
bewilderment. Gradually, the patient becomes withdrawn and isolated. Thus,
emotional coldness or lack of rapport can be felt even at the first interview and has
been described as 'having a pane of glass between you and the patient'.
Disorders of perception
Perception is distorted and external objects and events assume a different
meaning and significance. Hallucinations may occur, which may be auditory or
visual. Auditory hallucinations are the commoner of the two and take the form of
voices, talking about the patient and addressing him directly or echoing his thoughts.
The schizophrenic patient complains that voices comment on his actions, referring to
him in the third person.
Disorders of volition
The schizophrenic patient becomes passive and lacks the will and drive to go
through the day to day processes of living. He becomes more and more withdrawn
and asocial with diminished interest in the outside world. Personal hygiene and
appearance get neglected and there is a decline in personal, domestic, social and
occupational competence.
Passivity phenomena
These are very common and may take the form of:
(a) Thought insertion, i.e. thoughts being inserted into one's mind.
(b) Thought withdrawal, i.e. thoughts being removed or taken away from
one's mind.
39 UNDERSTANDING PSYCHIATRY
(c) Thought broadcasting, i.e. one's thoughts becoming known to the outside
world.
(d) Made feelings or impulses, i.e. feelings experienced as being imposed by
an outside force or agency.
Schizophrenic symptoms usually represent an increase or distortion of normal
functioning, i.e. positive symptoms, which are formal thought disorder, inappropriate
affect, disorganized behaviour, delusions and hallucinations. However, schizophrenic
symptoms also represent decrease or loss of normal functioning, i.e. negative
symptoms, which are blunt affect, poverty of speech and thought, impaired volition
and social withdrawal.
Clinical subtypes
Clinically, this sub-division into groups, is of a limited value and many patients
present with one type at one time and with another at another and there may be
considerable overlapping of symptoms.
1. Paranoid schizophrenia
2. Hebephrenic schizophrenia
3. Catatonic schizophrenia
4. Simple schizophrenia
5. Undifferentiated schizophrenia
Paranoid schizophrenia
It starts much later in life and persecutory delusions and auditory hallucinations
are prominent. Paranoid delusions may be transient or fixed. Delusions of
persecution are more common but personality is often well preserved for a number of
years. Sexual delusions are particularly common in middle aged women.
Disturbances of affect, volition and speech and catatonic symptoms are not
prominent.
Hebephrenic schizophrenia
The onset is insidious and the patient often presents with prominent affective
changes. Mood is inappropriate and speech is incoherent. There is a marked
volitional disorder and disorganization of personality. This type of illness is
characterized by the presence of gross delusions and hallucinations, which may be
fleeting and fragmentary. Hebephrenic schizophrenia accounts for a large number of
schizophrenic patients residing in the mental hospitals.
Catatonic schizophrenia
This usually has an acute onset and is characterised by motor abnormalities
accompanied by hallucinations and delusions. The patient's behaviour is withdrawn
and negativistic. Bizarre mannerisms, posturing and grimacing occur and a particular
posture may be maintained over a prolonged period of time. The patient may resist
attempts to alter postures or may become curiously malleable. This state is known as
waxy flexibility.
SCHIZOPHRENIA 40
Simple schizophrenia
The onset of the illness is insidious but there is progressive development of
oddities of conduct, inability to meet the demands of society and decline in total
performance. Delusions and hallucinations are not evident. The symptoms, at times,
can be traced back to childhood with history of eccentricities and odd behaviour but
the typical onset is in adolescence. There is loss of interest in studies and a
deterioration of school record. Relations with the family become strained. Simple
schizophrenics show extreme apathy and total lack of ambition or plans for the
future.
Undifferentiated schizophrenia
This includes those clinical pictures which do not seem to fit in any of the above
described types or which exhibit the features of more than one of them, without a
clear predominance of one or the other. This type should only be diagnosed after an
attempt has been made to classify the condition into one of the above four types.
Diagnosis
As no laboratory tests are available, detailed psychiatric history and mental state
examination are the only diagnostic tools currently available. According to the ICD-
10, at least one of the symptoms (a) - (d) or at least two of the symptoms (e) - (i)
should have been present during a period of a month or more:
(a) thought echo, thought insertion, thought withdrawal or thought broadcasting.
(d) persistent delusions of other kinds that are culturally inappropriate and
completely impossible, such as religious or of political identity or superhuman
powers and abilities.
(h) negative symptoms such as marked apathy, paucity of speech and blunting or
incongruity of emotional responses, usually resulting in social withdrawal and
lowering of social performance; it must be clear that they are not due to
depression or to neuroleptic medication.
(i) a significant and consistent change in the overall quality of some aspects of
personal behavior, manifesting as loss of interest, aimlessness, idleness, a self-
absorbed attitude and social withdrawal.
Some medical conditions that can give rise to a schizophrenia-like picture are
endocrine disorders, cerebral tumours, neurosyphilis, Wilson's disease, temporal lobe
epilepsy and other organic brain diseases, e.g. Huntington's disease and the adult
form of metachromatic Ieukodystrophy. In most cases focal findings suggest the
correct diagnosis. When these are lacking, the presence of true disorientation may
also be used as a fairly reliable indicator of the presence of a dementing illness.
1. Acute onset
2. Well integrated personality
3. Psychological or physical precipitating factors
4. Absence of family history of schizophrenia
5. A well preserved affective response
6. Stable work record
7. Catatonic symptoms
8. Harmonious family relationships
9. Some degree of confusion
10. Female gender
11. Low expressed emotions
12. Late age of onset
13. Early initiation of treatment
14. Above average intelligence
43 UNDERSTANDING PSYCHIATRY
Management
In cases where florid psychotic symptoms exist with deterioration in meaningful
relationships within the family, hospitalization is essential
Pharmacotherapy
It is now generally accepted that antipsychotic drugs play an important part in
the treatment of schizophrenia. Since the introduction of chlorpromazine, many other
phenothiazines and other classes of neuroleptic drugs have been introduced with very
good results. Apart from newer, atypical antipsychotics, e.g. clozapine and
resperidone, older neuroleptics have almost similar efficacy and indications but
different side effect profile. Extrapyramidal side effects are common. Akathesia, i.e.
generalized restlessness, is a very common side effect. Acute dystonic reactions like
abnormal face and body movements, tongue protrusion or torticollis may be seen
with drugs like phenothiazines and butyrophenones. Features suggestive of
Parkinsonism, like tremors, rigidity, mask like expression and pill rolling movements
of the fingers are also seen. Tardive dyskinesia is a serious complication, which
includes grimacing, tongue rolling and bizarre facial and body movements. In spite
of these side effects, these neuroleptics have been the mainstay in the treatment of
schizophrenia as they exert specific therapeutic effects and have proved very useful
in preventing relapse, especially when given for a period of 25 years. Compliance
can be a major factor in effective therapy and this can be improved by the use of long
acting phenothiazines or depot preparations in patients where compliance is doubtful
or unsatisfactory.
Psychotherapy
In schizophrenia, formal psychotherapy is of limited value. However,
psychotherapeutic approach is very important. Behaviour therapy and social skills
training are quite useful in chronic schizophrenic patients. An attempt should be
made to make contact with the patient because of the terrifying experiences, which
he might be having. Later, involvement in group therapy is useful.
Rehabilitation
This is perhaps the most important aspect in the treatment and maintenance of
remission in schizophrenia. An effort is made to provide favorable opportunities for
the patient, to re-establish meaningful relationships with other people. The
acceptance of patient's behaviour and communication helps him to develop
confidence and minimizes his anxiety. Occupational and industrial therapy is very
useful especially in chronic schizophrenic patients, so that they do not lose touch
with the day-to-day routine of living. In some cases, these patients can be taught new
trades in order to enable them to earn their living. The emphasis, now, is on keeping
the schizophrenic patients in the community and avoiding institutionalization.Psycho
educational and family intervention strategies based upon High Expressed Emotion
(HEE) of relatives ( e.g. Critical comments, hostility, emotional over involvement)
are helpful in preventing relapse.