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What is Schizophrenia?:

Definition- Schizophrenia is a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions. Although the course of schizophrenia varies among individuals, schizophrenia is typically persistent and can be both severe and disabling. (Schizophrenia, 2007)

About Schizophrenia- The condition involves a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation. Symptoms of schizophrenia are divided into positive, negative, and cognitive symptoms. Schizophrenia can be treated with antipsychotics which includes both typical and atypical antipsychotics. Along with the pharmacotherapy, psychosocial treatment is also done. (Schizophrenia, 2024)

Types of Schizophrenia:

Paranoid- Paranoid is the most common type of schizophrenia that develops later in life. Symptoms include hallucinations or delusions, but speech and emotions may not be affected. (Schizophrenia, 2024)

Hebephrenic- Hebephrenic, also known as ‘disorganized schizophrenia’, typically develops around ages 15-25. Symptoms include disorganized behaviors and thoughts, alongside short-lasting delusions and hallucinations. The patient may have disorganized speech patterns. (Schizophrenia, 2024)

Catatonic- Catatonic is the rarest of all schizophrenia diagnoses. The patient may often switch between being very active or very still. The patient may not talk much, and mimic other’s speech and movement. (Schizophrenia, 2024)

Undifferentiated- The patient's diagnosis may have some signs of paranoid, hebephrenic, or catatonic schizophrenia, but it does not fit into the other types. (Schizophrenia, 2024)

Residual- The patient may be diagnosed with residual schizophrenia if they have a history of psychosis, but only experience the negative symptoms such as slow movement, poor memory, lack of concentration, and poor hygiene. (Schizophrenia, 2024)

Simple- Negative symptoms of simple schizophrenia, slow movement, poor memory, lack of concentration, and poor hygiene, are most prominent early and worsen, while positive symptoms, hallucinations, delusions, and disorganized thinking, are rarely experienced. (Schizophrenia, 2024)

Cenesthopathic- Patients with cenesthopathic schizophrenia experience unusual bodily sensations. (Schizophrenia, 2024)

Unspecified- Symptoms of the patient meet the general conditions for a diagnosis but do not fit into any of the other types of schizophrenia. (Schizophrenia, 2024)

Treatments for Schizophrenia:''

Though there is no cure for schizophrenia there are lifelong treatments. There are two different types of treatments for schizophrenia, medicines and psychosocial therapy. A variety of antipsychotic medications are additive in reducing the symptoms present or potential future symptoms. Other treatments aim to reduce stress, support employment, and improve social skills. Diagnosis and treatment can be complicated by substance misuse. Patients with schizophrenia have a greater risk of substance-related disorders than the general population. If a patient shows signs of addiction, treatments for the addiction should occur. Antipsychotics can be taken orally as a pill, or given as an injection. Most people take medications for one or two years after their first psychotic episode to prevent further episodes. There are two main types of antipsychotics, typical antipsychotics and atypical antipsychotics. (Schizophrenia, 2024)

The side effects of typical antipsychotics:

• Shaking

• Trembling

• Muscle Twitches

• Muscle Spasms

The side effects of both typical antipsychotics:

• Drowsiness

• Weight Gain

• Blurred Vision

• Constipation

• Lack of Sex Drive

• Dry Mouth

Psychological treatment can help patients cope with symptoms of hallucinations or delusions better. Psychological therapies work best when combined with antipsychotic medications. (Schizophrenia, 2023)

Common psychological treatments include:

Family Therapy is when a patient with schizophrenia relies on family members for care and support. It involves a series of informal meetings over periods to help the individual and their family cope better with the conditions. (Schizophrenia, 2023)

Arts Therapy is used to promote creative expression. This therapy includes working with an art therapist in a small group or individually to allow expression in the patient's experiences with schizophrenia. (Schizophrenia, 2023)

Cognitive Behavioural Therapy (CBT) helps identify the patient's thinking patterns and what is causing one to have unwanted feelings and behavior, and learn to replace those thoughts with realistic and useful thoughts. (Schizophrenia, 2023)

Causes:

The exact causes of schizophrenia are unknown. Research suggests a combination of physical, genetic, psychological, and environmental factors can make a person more likely to develop the condition. Some people may be prone to schizophrenia, and a stressful or emotional life event might trigger a psychotic episode. However, it's unknown why some people develop symptoms while others do not. (Schizophreina, 2016)

Genetics: (Schizophrenia, 2016)

Schizophrenia tends to run in families, but no single gene is thought to be responsible. It's more likely that different combinations of genes make people more vulnerable to the condition. However, having these genes does not necessarily mean you'll develop schizophrenia. In identical twins, if a twin develops schizophrenia, the other twin has a 1 in 2 chance of developing it, too. This is true even if they're raised separately. In non-identical twins, who have different genetic make-ups, when a twin develops schizophrenia, the other only has a 1 in 8 chance of developing the condition.

Neruotransmitters: (Schizophreina, 2016)

Neurotransmitters are chemicals that carry messages between brain cells. Medicines that help lower the amounts of certain neurotransmitters, such as dopamine, can help with the symptoms of schizophrenia in some people. This suggests neurotransmitters play a role in the development of schizophrenia. Some studies indicate an imbalance between the two may be the basis of the problem. Others have found a change in the body’s sensitivity to the neurotransmitters is part of the cause of schizophrenia.

Brain Abnormalities: (Myers, 2007)

Researchers found that people with schizophrenia have thinner cortexes and show the largest differences in the frontal and temporal lobes. Noticeable decline in the brain waves that reflect synchronized neural firing in the frontal lobes. Many studies found enlarged, fluid-filled areas and a corresponding shrinkage of cerebral issues.

Pregnancy and Birth Complications: (Schizophrenia, 2016)

Research has shown people who develop schizophrenia are more likely to have experienced complications before and during their birth, such as: a low birth weight premature labour a lack of oxygen (asphyxia) during birth

Stress: (Schizophreina, 2016)

The main psychological triggers of schizophrenia are stressful life events, such as:

• bereavement

• losing your job or home

• divorce

• the end of a relationship

• physical, sexual, or emotional abuse

Drug Abuse: (Schizophrenia, 2016)

Studies have shown using drugs, particularly cannabis, cocaine, LSD, or amphetamines, can increase the risk of developing schizophrenia, psychosis, or a similar illness.

It is not clear if using drugs directly causes symptoms in people who are susceptible to schizophrenia, or if they are more likely to use drugs.

If people have previously had episodes of psychosis or schizophrenia, using drugs can cause a relapse or stop symptoms from getting better.

Research has shown that teenagers and young adults who use cannabis regularly are more likely to develop schizophrenia in later adulthood. The risk may be higher when using stronger forms of cannabis.

Case Study:

A 22-year-old girl was brought to the DHQ hospital in Faisalabad by her parents with presenting complaints of self-talk and self-laugh. They reported that their daughter suspects that somebody has cast black magic on her. She even skips her meal with a suspicion that someone has poisoned her food. She has been experiencing all the above complaints for the past year. On inquiring her no significant family history was found related to this disorder.

Past History: 3 years ago she was brought to the DHQ Hospital in Faisalabad when antipsychotics were prescribed to her. However, she stuck to the regimen just for one year and then showed noncompliance with her medication.

General Examination

•Weight: 46kg

•B.P: 110/70

•Temperature: 98 F

•Pulse Rate: 63 beats per minute

Special Investigation:

• Mental state examination (appearance, mood, behavior): neglected self-care, looking around, rapport, and eye contact was not established. Non-cooperative behavior throughout the interview.

• Positive and Negative syndrome scale (PANSS): delusions, hallucination, poverty of speech, disorganized behavior

Treatment: • Aripiprazole 15mg b.d

• Clonazepam 0.5mg h.s

• Psychotherapy session after every two weeks

Interventions:

• As the patient's history clearly shows that she has been non-compliant in the past an alternative intramuscular therapy can be recommended such as Fluphenazine (25mg/ml) IM after every two weeks.

• Secondly the patient was prescribed a 10mg tablet which she was advised to take as one and half tablet at a time. Instead of it, an alternative brand of Aripiprazole 15mg can be prescribed to resolve the compliance issue.

Outcomes and Follow-up:

• The outcomes of the treatment achieving life milestones, feeling safe, improved physical activity, employment, a positive sense of self, and psychosocial outcomes. Quality of life gets better and safety from harmful behaviors is achieved.

• The patient was advised to visit the psychiatrist for psychotherapy sessions.

Discussion:

A medication regimen must be followed to get its beneficial effects. This particular concept is of great importance for patients who have schizophrenia as they often show poor adherence and stopping medication has serious results. There have been several studies related to the non-adherence to antipsychotic medications. The majority of these studies have used subjective measures of adherence that rely on the patient, family member, or clinician reports, all of which have been shown repeatedly to overestimate adherence just a few studies have used an objective method like electronic monitoring to assess adherence to oral antipsychotic medication in outpatients who have schizophrenia. Remaining non-compliant with these medications leads to the worsening of clinical conditions, relapse of psychotic episodes, and hospitalization. Patients who have a history of non-compliance or have undergone frequent hospitalization need a long-acting intramuscular antipsychotic medication. Currently, three options exist: haloperidol decanoate, fluphenazine decanoate and lono actino risneridone.

Example: John Nash

Nash's mental illness first began to manifest in the form of paranoia; his wife later described his behavior as erratic. Nash seemed to believe that all men who wore red ties were part of a communist conspiracy against him; Nash mailed letters to embassies in Washington, D.C., declaring that they were establishing a government. Nash's psychological issues crossed into his professional life when he gave an American Mathematical Society lecture at Columbia University in 1959. Originally intended to present proof of the Riemann hypothesis, the lecture was incomprehensible. Colleagues in the audience immediately realized that something was wrong.

He was admitted to McLean Hospital in April 1959, staying through May of the same year. There, he was diagnosed with paranoid schizophrenia. According to the Diagnostic and Statistical Manual of Mental Disorders, or DSM, a person suffering from the disorder is typically dominated by relatively stable, often paranoid, fixed beliefs that are either false, over-imaginative, or unrealistic, and usually accompanied by experiences of a seemingly real perception of something not present. Further signs are marked particularly by auditory and perceptual disturbances, a lack of motivation for life, and mild clinical depression.

In 1961, Nash was admitted to the New Jersey State Hospital at Trenton. Over the next nine years, he spent periods in psychiatric hospitals, where he received both antipsychotic medications and insulin shock therapy.

Nash dated the start of what he termed "mental disturbances" to the early months of 1959 when his wife was pregnant. He described a process of change "from scientific rationality of thinking into the delusional thinking characteristic of persons who are psychiatrically diagnosed as 'schizophrenic' or 'paranoid schizophrenic."' For Nash, this included seeing himself as a messenger or having a special function of some kind, of having supporters and opponents and hidden schemers, along with a feeling of being persecuted and searching for signs representing divine revelation. Nash suggested his delusional thinking was related to his unhappiness, his desire to feel important and be recognized, and his characteristic way of thinking, saying, "I wouldn't have had good scientific ideas if I had thought more normally." He also said, "If I felt completely pressureless I don't think I would have gone in this pattern" He did not draw a categorical distinction between schizophrenia and bipolar disorder. Nash reported he did not hear voices until around 1964, and later engaged in a process of consciously rejecting them. He further stated he was always taken to hospitals against his will. He only temporarily renounced his "dream-like delusional hypotheses" after being in a hospital long enough to decide he would superficially conform — to behave normally or to experience "enforced rationality". Only gradually on his own did he "intellectually reject" some of the "delusionally influenced" and "politically oriented" thinking as a waste of effort. By 1995, however, even though he was "thinking rationally again in the style that is characteristic of scientists," he said he felt more limited

Schizophrenia changes how a person thinks and behaves. The condition may develop slowly. The first signs can be hard to identify as they often develop during the teenage years. Symptoms such as becoming socially withdrawn and unresponsive or changes in sleeping patterns can be mistaken for an adolescent "phase". People often have episodes of schizophrenia, during which their symptoms are particularly severe, followed by periods where they experience few or no symptoms. This is known as acute schizophrenia.

Positive and Negative Symptoms:(Schizophrenia, 2016)

• Positive symptoms: any change in behavior or thoughts, such as hallucinations or delusions

• Negative symptoms: a withdrawal or lack of function that would not usually be seen in a healthy person; for example, people with schizophrenia often appear emotionless and flat.

Hallucinations:(Schizophrenia, 2016)

• Hallucinations are where someone sees, hears, smells, tastes, or feels things that don't exist outside their mind. The most common hallucination is hearing voices.

• Research using brain-scanning equipment shows changes in the speech area in the brains of people with schizophrenia when they hear voices. These studies show the experience of hearing voices as a real one as if the brain mistakes thoughts for real voices.

Delusions: (Schizophrenia, 2016)

• A delusion is a belief held with complete conviction, even though it's based on a mistaken, strange, or unrealistic view. It may affect the way the person behaves.

• Some people develop a delusional idea to explain a hallucination they're having.

• Someone experiencing a paranoid delusion may believe they're being harassed or persecuted. They may believe they're being chased, followed, watched, plotted against, or poisoned, often by a family member or friend.

• Some people who experience delusions find different meanings in everyday events or occurrences. They may believe people on TV or in newspaper articles are communicating messages to them alone, or that there are hidden messages in the colours of cars passing on the street.

Confused Thoughts: (thought disorder) (Schizophrenia, 2016)

• People experiencing psychosis often have trouble keeping track of their thoughts and conversations.

• Some people find it hard to concentrate and will drift from one idea to another. They may have trouble reading newspaper articles or watching a TV program.

• People sometimes describe their thoughts as "misty" or "hazy" when this is happening to them. Thoughts and speech may become jumbled or confused, making conversation difficult for other people to understand.

Changes in Behavior and Thoughts: (Schizophrenia, 2016)

• A person's behavior may become more disorganized and unpredictable, and their appearance or dress may seem unusual to others.

• Schizophrenics may behave inappropriately or become extremely agitated and shout or swear for no reason.

• Some people describe their thoughts as being controlled by someone else, that their thoughts aren't their own, or that thoughts have been planted in their mind by someone else.

• Some people feel their body is being taken over and someone else is directing their movements and actions.

Negative Symptoms of Schizophrenia: (Schizophrenia, 2016)

Negative symptoms experienced by people living with schizophrenia include:

• losing interest and motivation in life and activities, including relationships and sex

• lack of concentration, not wanting to leave the house, and changes in sleeping patterns

• being less likely to initiate conversations and feeling uncomfortable with people, or feeling there's nothing to say.

The negative symptoms of schizophrenia can often lead to relationship problems with friends and family as they can sometimes be mistaken for deliberate laziness or rudeness.

Nash wrote in 1994:

I spent times of the order of five to eight months in hospitals in New Jersey, always on an involuntary basis and always attempting a legal argument for release. And it did happen that when I had been long enough hospitalized that I would finally renounce my delusional hypotheses and revert to thinking of myself as a human of more conventional circumstances and return to mathematical research. In these interludes of, as it were, enforced rationality, I did succeed in doing some respectable mathematical research. Thus there came about the research for "Le problème de Cauchy pour les équations différentielles d'un fluid général"; the idea that Prof. Hironaka called "the Nash blowing-up transformation"; and those of "Arc Structure of Singularities" and "Analyticity of Solutions of Implicit Function Problems with Analytic Data."

But after my return to the dream-like delusional hypotheses in the late '60s I became a person of delusionally influenced thinking but of relatively moderate behavior and thus tended to avoid hospitalization and the direct attention of psychiatrists.

Thus more time passed. Then gradually I began to intellectually reject some of the delusionally influenced lines of thinking that had been characteristic of my orientation. This began, most recognizably, with the rejection of politically oriented thinking as essentially a hopeless waste of intellectual effort. So at present, I seem to be thinking rationally again in the style that is characteristic of scientists.

References:

Bell, D. (2017). John Nash. Living with Schizophrenia. Retrieved June 4, 2024, from https://livingwithschizophreniauk.org/john-nash/

Jitender, A., Kartek, S., & Karandeep, P. (2018, November). Very early-onset psychosis/schizophrenia: Case studies of spectrum of presentation and management issues. National Library of Medicine. Retrieved June 4, 2024, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293945/

Mayo Clinic Staff. (2024, May 18). Schizophrenia. Mayo Clinic. Retrieved June 4, 2024, from https://www.mayoclinic.org/diseases-conditions/schizophrenia/diagnosis-treatment/drc-20354449

Rettner, R. (2015, June 4). "Beautiful Mind" John Nash's Schizophrenia "Disappeared" as He Aged (LiveScience, Ed.). Scientific American. Retrieved June 4, 2024, from https://www.scientificamerican.com/article/beautiful-mind-john-nash-s-schizophrenia-disappeared-as-he-aged/

Schizophrenia. (n.d.). National Institute of Mental Health. Retrieved June 4, 2024, from https://www.nimh.nih.gov/health/statistics/schizophrenia#:~:text=Schizophrenia-,Definition,be%20both%20severe%20and%20disabling

Torres, F. (Ed.). (2024, March). What is Schizophrenia? American Psychiatric Association. Retrieved June 4, 2024, from https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia

Types of Schizophrenia. (n.d.). Mental Health UK. Retrieved June 4, 2024, from https://mentalhealth-uk.org/help-and-information/conditions/schizophrenia/types-of-schizophrenia/