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Schizophrenia

Schizophrenia is defined by the psychiatric community (with the exception of some involved in the anti-psychiatry movement) as a group of severe psychotic mental illnesses. The name means "shattered mind", referring to the thought disorders that are the characteristic symptoms of schizophrenia.

Most researchers and clinicians currently believe that the basis of schizophrenia is primarily biological and results from the malfunctioning of dopamine pathways in the brain, as evidenced by the fact that medications which alter dopamine reuptake alleviate the symptoms of schizophrenia.

Although it is commonly confused by the public with multiple personality disorder, schizophrenia has nothing to do with the manifestation of distinct multiple personalities within a person. Instead schizophrenia is a condition with a mixture of symptoms that differ from patient to patient.

Table of contents

History Accounts that may relate to symptoms of schizophrenia date back as far as 2000 BC in Book of Hearts[?], a part of the ancient Ebers Papyrus[?].

Schizophrenia was first identified as a distinct mental disorder by Emil Kraepelin, the founder of modern scientific psychiatry. Kraepelin's original term for the disorder was dementia praecox, "early dementia" (to distinguish it as a separate disorder from senile dementia). He called it early dementia because his studies focused on young adults with dementia.

The term schizophrenia was coined by Eugene Bleuler[?]. It refers to the lack of interaction between thought processes and perception. He was the first to describe some of the symptoms as "negative."

Cause While most researchers and clinicians believe that schizophrenia is caused by some malfunction of the brain, there is no direct known cause for the illness.

Presentation (signs and symptoms) "Positive" symptoms include hallucinations, delusions, disordered speech, and disordered thought. "Negative symptoms" include lack of affect and apathy. Paranoia, withdrawal from social interaction, religious obsessions, and delusions of grandeur and/or persecution are common.

Hallucinations may be of any sensory modality - visual, auditory, olfactory, gustatory, tactile or mixed - although auditory and visual hallucinations are the most common in that order.

Many individuals hear "voices". Voices vary in content, from a running commentary, to warning the person against various people or activities or instructing that person in actions to take. A person can hear multiple distinct voices, and the voices can be people they know or do not know. PET scans of the brain of a person with schizophrenia indicate that when a patient is hallucinating, the brain undergoes activity exactly the same as when the patient is hearing an actual voice or seeing an actual object. These voices are often distressing to those who experience them.

Delusions that have been commonly accepted as being part of schizophrenia include:

  • belief that he/she has power over other people's minds or that other people have power over his/her mind
  • belief in being able to read other people's thoughts or that other people can read their thoughts
  • belief that there are special personal messages for them in the mass media (newspapers or radio or television) ("delusions of reference")
  • belief that he/she has a special link to God or indeed is God
Delusions held by schizophrenics are unshakeable and must be incompatible with the culture from which the patient comes from.

"Negative" symptoms affect attention, memory, concentration and learning and can include social withdrawal, lack of emotional responsiveness, and lack of initiative. Although the "positive" symptoms are much more dramatic, they are also much more easily treatable with antipsychotics. Negative symptoms have traditionally been less affected by antipsychotics although there has been a new class of "atypical antipsychotics" which has been useful in treating these aspects of schizophrenia. The drugs used to treat schizophrenia have the primary effect of blocking dopamine receptors in the brain.

Symptoms of schizophrenia often overlap with other "major mental illnesses", particularly mood disorders or Obsessive-Compulsive Disorder. The term "schizoaffective disorder" is used for situations where an individual has the distinct "thought disorder" symptoms of schizophrenia, combined with "mood disorder" symptoms usually associated with bipolar disorder or depression. Unlike other major mental illnesses, patients with schizophrenia do not have periods between attacks of the disease in which they are able to return to full functioning without medication.

Prognosis The first schizophrenic episode typically occurs between the ages of fifteen and thirty. Men typically develop the symptoms five to ten years earlier than women. In about a third of the cases, the patient will suffer psychotic episodes for a few months and then make a complete recovery without treatment.

The symptoms of the illness tend to improve later in life correlated to decreases in the neurotransmitter dopamine. Schizophrenia is incurable, but can be "treated" with antipsychotic drugs, and as such has been compared to diabetes, which cannot be cured but may be treated with insulin. These drugs can have many unpleasant side effects; many patients may stop taking their medication as a result of extrapyramidal side-effects (EPSE), a variety of movement disorders (see link at end of article for description). Controlled studies have shown that "insight-oriented" psychotherapy in which the patient is asked to understand the causes of their mental states is useless in the treatment of schizophrenia and tend to make the symptoms worse.

There is also an extremely high suicide rate associated with schizophrenia, with most suicides occurring within the first few years after diagnosis.

Diagnosis

Treatment Treatments which are now considered ineffective include psychosurgery, electroconvulsive therapy, and insight-oriented psychoanalysis. Insulin shock treatment is also no longer used.

However, if the condition relapses, the probability of spontaneous recovery decreases. A rule of thumb is that one third of persons with a psychotic episode will recover fully with or without treatment. One third will be able to lead relatively independent lives with continued treatment, and one third will be unable to live independently even with medication.

General practice for the treatment of schizophrenia is to emphasize "supportive psychotherapy" in which the focus of the treatment is to help the patient deal with the day to day problems that arise as the result of the disease.

Contrary to popular belief, persons with schizophrenia are not dangerous to strangers. Persons undergoing treatment for schizophrenia do not have a significantly higher rate of violence than the general population. Persons with schizophrenia who are not under treatment are said to have significantly higher rates of violence, but even in this case the target of the violence are generally family members and close relations rather than strangers. Persons with active schizophrenia have difficulty with planning, and, as a result, crimes committed by persons with schizophrenia tend to be of an extremely impulsive nature. Schizophrenia is blamed in most of the criminal cases in which the insanity defense is used.

Incidence and Prevalence Schizophrenia is the most common form of major psychosis; it is estimated that over 45 million people are affected worldwide. The pathogenesis of schizophrenia is not fully understood but there is some evidence suggesting that the basis of this disease is disruption to the balance of chemical messengers and nerve pathways in the brain, and it appears that a combination of both genetic and environmental factors is necessary to cause schizophrenia. In cases where one identical twin has schizophrenia, there is a 60 percent chance that the other twin will also have the disease. This illustrates that there is a strong genetic component to the disease, but that genetics is not the only factor. Psychiatrists generally do not believe as they once did that the origin of the disease can be traceable to child rearing practices.

Categories Historically, schizophrenia in the West was classified into simple, catatonic, hebephrenic[?] and paranoid. Current diagnostic criteria identify four types: paranoid in which there are delusions of persecution but no flattened affect; catatonic, in which there is lack of movement; disorganized, in which there is disorganized speech; and undifferenated, in which none of the above symptoms are present. In addition to the above, there is the the residual type, in which the patient does not actively display full symptoms of schizophrenia, but some disturbance is evident.

In the former Soviet Union, a fifth form of the disease, termed "sluggishly progressing schizophrenia[?]" was added. Particularly in the RSFSR (Russian Soviet Federated Socialist Republic), political dissidents were diagnosed with "sluggishly progressing schizophrenia" and confined to psychiatric hospitals for the purpose of silencing them or forcing them to recant their ideas. Western psychiatric practice attempts (with greater or lesser success) to prevent such abuses by regarding only as delusional beliefs which are not sanctioned by the patient's cultural environment and by focusing on the physical danger a patient may present to him or others, rather than on non-conforming behavior, as the criteria for involuntary commitment; however, there have been accusations by the anti-psychiatry movement and by members of the consumer survivor movement, as well as by surrealism, that these psychiatric abuses exist to some extent in the West as well. (See "Schizophrenia and Anti-Psychiatry" below.) Some have challenged the residual type of schizophrenia as being similar to "sluggishly progressing schizophrenia."

The first four, widely varying, forms of schizophrenia have led some to pose the question, "Is schizophrenia one illness, or different illnesses that have been mistakenly classified under one heading?" At present the evidence is not clear, and the idea that schizophrenia may be a cluster of related diseases is one which most practioners do not consider objectionable. It is known, for example, that patients with paranoid delusions respond to medication much more effectively than patients with catatonic symptoms, and these differences may be due to underlying differences in the causes of the diseases.

Schizophrenia and drug use Schizophrenia can sometimes be triggered by heavy use of hallucinogenic drugs, especially LSD; but it appears that one has to have a predisposition towards developing schizophrenia for this to occur. There is also some evidence suggesting that people suffering schizophrenia but responding to treatment can have an episode as a result of use of LSD. Methamphetamine and PCP also mimic the symptoms of schizophrenia, and can trigger ongoing symptoms of schizophrenia in those who are vulnerable. There is also some evidence that marijuana usage can be a contributing trigger to schizophrenia in vulnerable individuals.

It has been noted that the majority of schizophrenics smoke tobacco, presumably as a form of self-medication. Estimates for the number of schizophrenics that smoke range from 75% to 90%. Schizophrenics, however, have a much lower than average chance of getting and dying from lung cancer. While the reason for this is unknown, it may be because of a genetic resistance to the cancer, a side-effect of drugs being taken, or a statistical effect of increased likelihood of dying from causes other than lung cancer.

Alternative Approaches to Schizophrenia

Schizophrenia and Anti-Psychiatry

A far more controversial position is taken by some supporters of anti-psychiatry, a movement which came out of the 1960s that claimed that psychiatric patients are not ill and that they are just individuals that are misfits in society, and are therefore put into asylums.

Anthropological studies have claimed that roughly equivalent percentages of people in a variety of cultures, some very different to modern Western culture, develop a disease recognised by that culture as such, with similar symptoms to schizophrenia, and subsequent medical examination of afflicted individuals show similar physical abnormalities as schizophrenics, but the lower rates of diagnosis for the forms of schizophrenia accepted in the West in Western Europe than in the United States of America, to question whether it is possible that in some cases schizophrenia is not deliberately misdiagnosed in the United States as a means of political or philosophical repression. DSM IV-TR[?] also notes that there is "a far higher incidence [of schizophrenia] for second generation African Caribbeans living in the United Kingdom."

Some supporters of this view, such as Thomas Szasz and R. D. Laing[?], go as far as to maintain that schizophrenia does not exist. This position is held by only a small minority and is highly controversial.

Other supporters who are active in anti-psychiatry have not gone so far as to challenge the illness of psychiatric patients but merely challenged the practice of involuntary commitment from a legal or civil liberties perspective.

Other Approaches

Researchers into shamanism have speculated that in some cultures schizophrenia or related conditions may predispose an individual to becoming a shaman. This assertion is highly criticized by psychiatrists.

The 1976 book The Origin of Consciousness in the Breakdown of the Bicameral Mind, by psychologist Julian Jaynes proposed that until the beginnings of historic times schizophrenia or a closely similar condition was the normal human consciousness; a "bicameral mind" in which a normal state of low affect suitable for routine activities would be interrupted in moments of crisis by "mysterious voices" giving instructions, which early people characterized as interventions from the gods. This theory was briefly controversial but continued work has not provided additional support.

Alternative medicine tends to hold the view that schizophrenia is primarily caused by imbalances in the body's reserves and absorption of dietary minerals[?], and/or the presence of heavy metals.

Famous Schizophrenics

References

  • "Conditions in Occupational Therapy: effect on occupational performance." ed. Ruth A. Hansen and Ben Atchison (Baltimore: Lippincott Williams & Williams, 2000), 54-74. ISBN 0-683-30417-8
  • Kraepelin, Emil. "Dementia praecox and paraphrenia". trans. R. Mary Barclay. ed. George M. Robertson. (Huntington, N.Y., R. E. Krieger Pub. Co., 1971). xxiv, 331 p. illus., facsims. 23 cm. ISBN 1-855-06974-1 (The classic text on schizophrenia)
  • Psychiatrie. 8. Aufl., Bd. 1: Allgemeine Psychiatrie; Bd. 11: Klinische Psychiatrie, 1. Teil. Barth, Leipzig 1909. Bd. 111, 1913; Bd. IV, 1915. (Translation of section on the disease from the German)

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