What is Schizophrenia?

Schizophrenia is a type of psychotic disorder with a specific pattern of symptoms and behaviours.  Psychosis has been used to describe a situation when a person loses touch with the outer reality. The person may have different symptoms including hallucinations, delusions, or thought disorders. Psychotic symptoms are at the core of schizophrenic illness. The distinguishing features of psychosis in a patient suffering from Schizophrenia are that they are chronic, longer lasting, stable (i.e. symptoms don’t change frequently).  It may also be that they are more bizarre and associated with incongruent moods and are more disabling than other type of psychosis. Thus, it is important to rule out other possibilities before making a diagnosis of Schizophrenia.

What are the symptoms of schizophrenia?

Broadly there are two categories of symptoms i.e. the positive symptoms and negative symptoms. Positive symptoms are unusual experiences or behaviours that are in addition to the normal functioning e.g. Delusions or Hallucinations. Negative symptoms are behaviours or experiences which are now lacking but were present before e.g. decreased interest to do normal tasks, low energy levels or decreased motivation to talk to others.

Positive Symptoms:

• Delusions: These are unusual and unshakable beliefs held by the individual which are believed to be false by others around them. Beliefs like “The anchor in the TV show is talking about me and giving me signals” or “I can make it rain on my wish”. The patient has full belief in them and holds the belief even when sufficient evidence to the contrary is presented to them.
• Hallucinations: It is an experience of sensation like sound, smell, taste, vision, touch felt by a person without having any source to cause it e.g. being able to hear someone shouting one’s name despite no one being around.
• Thought disorder: This involves a problem in constant flow of thoughts or being able to properly organise one’s own thought. Patient may appear to jumble words/sentences or say words without any meaning.
• Catatonia: In this there is an impaired ability of the patient to move or speak in a normal manner. The patient may appear to be in uncomfortable postures for a long time or may say words or actions repeatedly. However few patient paradoxically may even become excited and agitated.

Negative Symptoms:

• Lack of interest in activities previously enjoyed
• Inability to talk to others or share feelings
• Decreased emotional reaction
• Decreased socialisation
• Struggling with the basics of daily life.

Not every patient has all the symptoms, but there can be a single or a combination of symptoms in every patient. Usually the patient does not believe that there is anything wrong with them and thus does not acknowledge any unusual behaviour as a symptom.

What are the causes of Schizophrenia?

Almost one in every 100 persons throughout their lifetime is affected by schizophrenia. These rates are similar in both men and women and the onset is usually in 20’s.  The chances of offspring having schizophrenia increase up to 10 % if either parent have the disease. But apart from genetics other factors like stress, illicit drugs, alcohol, and brain damage, etc may precipitate the disease. Recent insights into the causation of the illness shows that there can be a combination of biological, social, psychological and genetic factors. In brain there can be an imbalance in the levels of naturally occurring brain chemicals or neurotransmitters DOPAMINE and GLUTAMATE or there may be an actual change in the brain structure from normal brain. These changes when interact with psychological and social stressors may precipitate the disease.  The use of antipsychotics leads to a correction of dopamine overactivity.

Is Schizophrenia and schizoaffective similar?

Schizoaffective disorder are the disorders where one sees a combination of psychotic symptoms as well as mood symptoms. The distinguishing feature of schizoaffective disorders from the above two categories is that the mood symptoms and the psychotic symptoms exist independent of each other if we look at the long-term pattern of the illness. And there are periods of overlap between them.

Is having paranoia normal?

Paranoia is a symptom itself and not a diagnosis. If very brief, it may be a part of the normal experiences for many individuals. With individuals having Paranoid personality disorder these experiences may be more frequent and involve more than one situation. They have issues with trusting others and are even suspicious at times. These symptoms are usually there since teenage, but this behaviour is neither odd nor bizarre in nature like the experience of patients with schizophrenia. Usually these individuals function well and have problems only when there are extreme situations, or these paranoid ideas interfere with the situation.  The main difference between paranoid personality disorder and paranoid psychosis in schizophrenia is that psychotic patients suffer with clear cut delusions which are deeply entrenched.

Are patients with Schizophrenia violent?

Many people think that patients with Schizophrenia are violent, which increases the stigma associated with the illness. The risk of violence in patients with Schizophrenia is only two-fold higher than general population. Higher risk is associated with those who use substances. Patients with Schizophrenia are more prone to be victims of violence than the perpetrators. Less than 10% patients diagnosed may be violent in their lifetime.

How do I know I have Schizophrenia?

Majority of patients who have this illness won’t even recognise that something is wrong with them, as they would have lost insight. Due to this there is hesitancy to take any treatment or medication without which the disease might progress and become more difficult to treat eventually. It is therefore best to listen to your well-wishers such as family and friends and the professionals. The patient cannot be the best judge of their situation.

Is there a treatment for Schizophrenia?

Before initiating medications, a detailed history from the patients and a family member is taken. After that the patient is examined for any neurological signs, atypical symptoms of presentation or dysfunction in brain etc.  In addition, some blood investigations like complete hemogram, liver and kidney function tests, blood sugar, serum lipid profile, urine routine examination, and electrocardiogram may be done at baseline before initiating treatment.

It must also be understood that psychoeducation of the patient and family members is an important step which should be followed at each step, beginning from assessment to initiating the medications, and monitoring the progress. The patient and family members should understand that antipsychotics do not “cure” schizophrenia but treat the symptoms just the way insulin treats diabetes.

The antipsychotics are divided into two broad categories: the first-generation and the second generation. The first generation are relatively older molecules e.g. Haloperidol, Trifluoperazine, and these drugs act specifically on dopaminergic areas of brain. Thus due to their highly specific action on dopamine they are associated with higher chances of side effects such as rigidity, tremor, abnormal movements, Parkinson like symptoms etc.

The second-generation antipsychotics such as Aripiprazole, Olanzapine etc. have a relatively less specific action on Dopamine thus the chances of movement related side effects are less. In addition to dopaminergic areas, they also act on other brain areas like serotonin receptors, Glutamate receptors etc. But these drugs come with a higher risk of weight gain, obesity, change in lipid levels etc.

Overall, there is no evidence that second generation antipsychotics are clinically more effective than first generation, and the decision of which is to be preferred in a given individual is taken after discussing the side effect profile of a given drug.

Where should I seek help from?

If you or your dear ones are having symptoms mentioned above with significant distress or problems in carrying normal activities, you should consult your psychiatrist immediately. The psychiatrist will evaluate thoroughly for the symptoms of Schizophrenia, whether you require treatment or not and order any investigations if required. After relevant examination, the decision to treat on out-patient or in-patient basis is taken. The cases where admission may be indicated are – if there is a high suicidal risk, inability to take adequate self-care, danger to others, need for intensive therapy, or any medical/psychiatric complication.

Recommended Reading:

• Schizophrenia | Royal College of Psychiatrists. RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS. Available from: https://www.rcpsych.ac.uk/mental-health/problems-disorders/schizophrenia
• Schizophrenia for young people | Royal College of Psychiatrists. RC PSYCH ROYAL COLLEGE OF PSYCHIATRISTS. Available from: https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/schizophrenia-for-parents-and-carers