Department of Psychiatry at Far Eastern Memorial Hospital

Schizophrenia is a severe, chronic and disabling brain disorder characterized by impairments in perception, cognition, and social and occupational functioning. It affects about 1 percent of the population worldwide. Psychotic symptoms (such as hallucinations and delusions) usually emerge in men in their late teens and early 20s and in women in their mid-20s to early 30s. They seldom occur after age 45 and only rarely before puberty.

Causes and Risk Factors. Although there is a genetic risk for schizophrenia, it is not likely that genes alone are sufficient to cause the disorder. Interactions between genes and the environment are thought to be necessary for schizophrenia to develop. Many environmental factors have been suggested as risk factors, such as exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors, like stressful environmental conditions. Imbalance in the chemical reactions of the brain involving the neurotransmitters dopamine and glutamate (and possibly others) also plays a role in schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with one another.

Symptoms of schizophrenia are divided into 3 categories:

Positive symptoms. These are unusual thoughts or perceptions which are out of touch with reality and may include delusions, hallucinations, and thought disorder. Patients may hear voices other people don't hear (hallucination) or they may believe that others are reading their minds, controlling their thoughts, or plotting to harm them (delusions). These experiences are terrifying and can cause fearfulness, withdrawal, or extreme agitation. People with schizophrenia may not make sense when they talk, may sit for hours without moving or talking much, or may seem perfectly fine until they talk about what they are really thinking.
Negative symptoms. These are reductions in normal emotional and behavioral states which may include flat affect (immobile facial expression, monotonous voice), lack of pleasure in everyday life, diminished ability to initiate and sustain planned activity, and speaking infrequently, even when forced to interact.

People with schizophrenia often neglect basic hygiene and need help with everyday activities. Because it is not as obvious that negative symptoms are part of a psychiatric illness, people with schizophrenia are often perceived as lazy and unwilling to better their lives.
Cognitive symptoms. These symptoms are often detected only when neuropsychological tests are performed. They may include poor "executive functioning" (the ability to absorb and interpret information and make decisions based on that information), inability to sustain attention, and problems with "working memory" (the ability to keep recently learned information in mind and use it right away) Cognitive impairments often interfere with the patient's ability to lead a normal life and earn a living. They can cause great emotional distress.

Because many people with schizophrenia have difficulty holding a job or caring for themselves, the burden on their families and society is significant as well.

Violence and Schizophrenia. People with schizophrenia are not especially prone to violence and often prefer to be left alone. Most violent crimes are not committed by people with schizophrenia, and most people with schizophrenia do not commit violent crimes. Studies show that the rate of violence in people with schizophrenia is not different from that of the general population. If someone with paranoid schizophrenia becomes violent, the violence is most often directed at family members and takes place at home. Substance abuse increases violent behavior, regardless of the presence of schizophrenia.

Suicide and Schizophrenia. About 20% of schizophrenia attempts suicide and of these, 10 percent (especially young adult males) succeed. It is hard to predict which people with schizophrenia are prone to suicide, so if someone talks about or tries to commit suicide, professional help should be sought right away.

Treatment

1.) Antipsychotic Medications
These medications effectively alleviate the positive symptoms of schizophrenia. Everyone responds differently to antipsychotic medication. Sometimes several different drugs must be tried before the right one is found. People with schizophrenia should work in partnership with their doctors to find the medications that control their symptoms best with the fewest side effects.

Although agitation and hallucinations usually improve within days and delusions usually improve within a few weeks. Many people see substantial improvement in both types of symptoms by the sixth week of treatment. No one can tell beforehand exactly how a medication will affect a particular individual, and sometimes several medications must be tried before the right one is found.

When people first start to take atypical antipsychotic, they may become drowsy; experience dizziness when they change positions; have blurred vision; or develop a rapid heartbeat, menstrual problems, a sensitivity to the sun, or skin rashes. Many of these symptoms will go away after the first days of treatment, but people who are taking atypical antipsychotic should not drive until they adjust to their new medication.

If people with schizophrenia become depressed, it may be necessary to add an antidepressant to their drug regimen.

Length of Treatment. Like diabetes or high blood pressure, schizophrenia is a chronic disorder that needs constant management. At the moment, it cannot be cured, but the rate of recurrence of psychotic episodes can be decreased significantly by staying on medication. Although responses vary from person to person, most people with schizophrenia need to take some type of medication for the rest of their lives as well as use other approaches, such as supportive therapy or rehabilitation.

Relapses occur most often when people with schizophrenia stop taking their antipsychotic medication because they feel better, or only take it occasionally because they forget or don't think taking it regularly is important. It is very important for people with schizophrenia to take their medication on a regular basis and for as long as their doctors recommend.

No antipsychotic medication should be discontinued without talking to the doctor who prescribed it, and it should always be tapered off under a doctor's supervision rather than being stopped all at once.

There are a variety of reasons why people with schizophrenia do not adhere to treatment. If they may not believe they are ill, hence no need for treatment. If their thinking is too disorganized, they may not remember to take their medication every day. If they don't like the side effects of one medication, they may stop taking it without trying a different medication. Substance abuse can also interfere with treatment effectiveness. Doctors should ask patients how often they take their medication and be sensitive to a patient's request to change dosages or to try new medications to eliminate unwelcome side effects.

There are many strategies to help people with schizophrenia take their drugs regularly. Medications are available in long-acting, inject able forms, which eliminate the need to take a pill every day. Medication calendars or pillboxes labeled with the days of the week can both help patients remember to take their medications and let caregivers know whether medication has been taken.

Medication Interactions. Antipsychotic medications can produce unpleasant or dangerous side effects when taken with certain other drugs. Therefore, all concomitant medications (including herbal supplements, over-the-counter and prescription medications, vitamins and minerals, etc) should be discussed with the doctor who prescribes the antipsychotic.

2.) Psychosocial Treatment
Psychosocial treatments can help patients who are already stabilized on antipsychotic medications deal with certain aspects of schizophrenia, such as difficulty with communication, motivation, self-care, work, and establishing and maintaining relationships with others. Learning and using coping mechanisms to address these problems allows people with schizophrenia to attend school, work, and socialize. Patients who receive regular psychosocial treatment also adhere better to their medication schedule and have fewer relapses and hospitalizations. The therapist gives the patient a reliable source of information, sympathy, encouragement, and hope. They can help patients better understand and adjust to living with schizophrenia by educating them about the causes of the disorder, common symptoms or problems they may experience, and the importance of staying on medications.

Rehabilitation. Rehabilitation emphasizes social and vocational training to help people with schizophrenia function more effectively in their communities. Because people with schizophrenia frequently become ill during the critical career-forming years of life (ages 18 to 35) and because the disease often interferes with normal cognitive functioning, most patients do not receive the training required for skilled work. Rehabilitation programs can include vocational counseling, job training, money management counseling, assistance in learning to use public transportation, and opportunities to practice social and workplace communication skills.

Family Education. Patients with schizophrenia are often discharged from the hospital into the care of their families, so it is important that family members know as much as possible about the disease to prevent relapses. Family members should be able to use different kinds of treatment adherence programs and have an arsenal of coping strategies and problem-solving skills to manage their ill relative effectively. Knowing where to find outpatient and family services that support people with schizophrenia and their caregivers is also valuable.

Reference:
National Institute of Mental Health “Health Information on Schizophrenia”