Understanding schizophrenia

Dr Meesha Haorongbam *

Schizophrenia is a psychotic disorder meaning that someone suffering from schizophrenia will be unable to distinguish between the real and the imaginary. This brain disorder strikes persons as they are entering the prime of their lives and in many cases, runs a recurrent and ultimately chronic course that leads to substantial disability.

This most devastating of mental illness affects the essence of what make people human- their personality and intellect. For these reasons schizophrenia is considered the prototypic mental illness.

More than any other mental illness, schizophrenia is synonymous in the public’s mind with “madness”: the family member who suddenly believed the neighbours are sending poisonous gas through the walls, the friend who is convinced that the neighbour had planted cameras to spy on him, and the colleague who believed that people around him can read his thoughts.

Schizophrenia is neither new nor rare. It has likely existed for centuries, if not millennia. It’s one of the leading causes of disability in the world, with a lifetime prevalence of about 1% of the population.

The lifetime prevalence among Indians is slightly lower (0.4%) according to the National Mental Health Survey 2015-16. According to latest data, it’s prevalence is 24 million people worldwide i.e., 1 in every 300 individuals are affected with schizophrenia. Schizophrenia is a low incidence but a high prevalence disease, meaning that relatively few people develop it each year (15.9 per 100000 people) but once you develop it you have it for life.

ONSET OF SYMPTOMS

Schizophrenia is equally prevalent in men and women but onset is earlier in men than women. The peak ages of onset are 10-25 years for men and 25-35 years for women. Onset of schizophrenia before 10 years of age or after age 60 years is rare but not unheard of. Before the illness truly manifests, there is a stage called the prodrome when it slowly becomes apparent to anyone paying attention that all is not well.

The problem is that prodromal symptoms mirror what many healthy teenagers experience in their routine passage through adolescence: sleep irregularities, difficulty in concentrating, vague feelings of tension or anxiety, a change in personality and perhaps a withdrawal from their peers.

Often, parents will realize (after their child has been diagnosed with schizophrenia) that there had been an identifiable period of foreshadowing during which time they’d wondered if their child was struggling with depression or their inability to cope with the stress of growing up.

SYMPTOMS

The symptoms of schizophrenia manifest gradually before crystallizing in three distinct forms:

1. Positive symptoms- Some common positive symptoms are:

o Hearing voices not heard by others (e.g. voices giving a running commentary about his actions, voices commanding him to carry out certain uncomfortable or distressing tasks)
o Believing that his thoughts are being withdrawn from him or inserted into him or that his thoughts are being broadcasted everywhere
o Believing that some external agencies are moving his limbs against his will or that his emotions are being forced against his will
o Delusions (e.g. believing that his food is being poisoned, or that microchips had been implanted in his brain to gain access to his thoughts or that certain people have conspired to get him killed, etc)

2. Negative symptoms-

o Lack of feeling or emotion
o Inability to experience pleasure
o Poor non-verbal communication by facial expression, eye contact, voice modulation
o Poor self-care
o Decreased motor activities

3. Cognitive symptoms-

o Limited attention span
o Memory impairments
o Lack of ability to solve problem, strategically plan and organize

Schizophrenia basically affects all aspects of a person’s life- thought, perception, emotion, cognition and this makes it a challenging illness, causing enormous difficulties to them and their loved ones. While the florid psychotic/positive symptoms are quite dramatic and bizarre and concerning and is usually what makes a person seek treatment in the first place, the cognitive symptoms are principally responsible for the enduring functional difficulties experienced by people with schizophrenia.

These problems relate to such basic life management skills as personal hygiene, scheduling and planning, social interaction, relationships, financial management, education, and work.

COURSE

The illness isn’t something you contract and get over, like chickenpox or pneumonia. It is more like diabetes or hypertension, a condition that doesn’t go away but that you can live with if you have appropriate treatment. Schizophrenia has a remitting and relapsing course but it is quite heterogenous even with treatment i.e.

o 30-40% will have only one episode
o 30-40% may have two or more episodes
o 10-20% may become manageable but continue to have some symptoms
o 10% of patients may not improve in spite of best treatment

CAUSES AND RISK FACTORS

The current scientific understanding is that schizophrenia is a brain disorder caused by genes and/or environmental trauma, including social determinants of health, such as malnutrition, birth trauma, and poverty, that affects brain development and produce neurochemical changes and structural alterations.

Schizophrenia is an equal opportunity illness. Gender, race, ethnicity, affluence, education- none of these provides immunity from schizophrenia. However, there are certain individuals who are at a higher risk of developing schizophrenia-

1. Family history of schizophrenia (especially in first degree relatives)
2. Prenatal exposure to toxins & infections
3. Malnutrition, extreme prematurity, hypoxia or ischaemia during pregnancy and birth
4. Advanced paternal age
5. People with autoimmune diseases
6. Substance use especially cannabis dependence
7. Urban residence

TREATMENTS

Medications are absolutely essential for effective management of schizophrenia. Other treatment modalities such as electroconvulsive therapy, psychoeducation, family intervention, and rehabilitation are necessary but medications are the first line of treatment. Treating schizophrenia is complicated by its heterogeneity and by the need to intervene early.

Timely, affective treatment can produce remission of symptoms and enable recovery in most patients. But if the illness goes untreated, or there are repeated relapses, their mental faculties start to deteriorate until they are unable to function normally.

Without treatment, they’re defenceless against the ravages of schizophrenia, their lives often shortened by decades due to the medical complications and the societal neglect that the illness imposes. With timely treatment, people suffering from schizophrenia can lead healthy and meaningful lives and contribute significantly to society.

One of the most famous examples is renowned mathematician Prof. John Nash who, despite suffering from schizophrenia, won the Nobel Prize in Economics. His life is a testament to what someone with schizophrenia can achieve with support from family and loved ones and timely and effective intervention.

WORLD SCHIZOPHRENIA DAY

In earlier times, when the causes and treatment of mental illnesses were barely known, mentally ill patients in asylums were often restrained to walls by chains in the wrong assumption that it would help control their symptoms. On 24th May 1793, Philippe Pinel, the man who is considered as the Father of Modern Psychiatry, unchained the patients in an asylum in France in the hopes of preserving their dignity as human beings.

In honour of Pinel and his early efforts to provide humane care and treatment to the mentally ill, every year since 1984, 24th May is observed as World Schizophrenia Day in the hope that worldwide observation of the day would help educate the public about schizophrenia, reduce stigma and discrimination faced by people with schizophrenia and challenge the misconceptions and stereotypes surrounding this disorder arising out of brain malfunctioning.

World Schizophrenia Day aims to instil hope in people whose lives have been affected by this illness so that with early intervention the symptoms can be effectively managed andthey can go own to lead meaningful lives.

The very first step is to change our attitude towards people with schizophrenia and the words we use to talk about them. Remember, people with this illness are not schizophrenics. They have schizophrenia.

And they can be your spouse, parent, sibling, or colleague. A diagnosis of schizophrenia need not be a death sentence; one can be mentally ill and still lead a rich and satisfying life with the right treatment and support.