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DEFINITION Schizophrenia is a psychotic illness, which in its active phase includes delusions, hallucinations, disruption of the ability to think and of many other mental functions.
Many cases run a chronic course leaving residual psychiatric symptoms and impaired social functioning, in respect of relationships, study and work. A patient with an acute episode is the general publicís idea of a ěmadî person, and probably as a consequence, schizophrenia is often considered the most serious of all psychiatric conditions. It has gained more public prominence in recent years, since patients who would once have spent their lives in the old ěasylumî mental hospitals now live in the community. ěCare in the communityî has generally been a success, but a few problem cases (for example the tragic death of Jonathan Zito) have tended to make the public think the opposite.
FREQUENCY Schizophrenia seems to have become less common- and also less severe- in recent years, at any rate in developed countries. The lifetime risk of getting the condition is approximately 1%. There are about 15 new cases per hundred thousand population per annum.
EPIDEMIOLOGY
- age: the condition usually begins in late adolescence or early adult life, though it can be before puberty in rare cases, and occasionally in later life.
- sex: schizophrenia is equally common in men and women, but tends to start at a younger age in males.
- marital status: patients are more likely to be single, than the average member of the population, due both to problems in forming relationships and to increased relationship breakdown.
- fertility is reduced, though it remains unclear whether there are additional biological factors responsible, or whether it is due to the aforementioned relationship difficulties.
- social class: schizophrenia is commoner in lower social socioeconomic groups. This is probably due to the patient, drifting down the social scale, before the onset of the illness. The original social class of new patients with schizophrenia, as defined by fatherís occupation, is distributed according to the distribution of social class in the population.
- country the frequency of schizophrenia is roughly the same in most countries; in the countries where there is a different figure, this has generally been found to be due to different criteria for the diagnosis of the condition. In the 1970s, an international survey found that psychiatrists in the UK, and a number of other countries, diagnosed schizophrenia much less frequently than their counterparts in the US, and also in Russia, where the socialist regime misused psychiatry to confine dissidents.
CAUSATION of
- the condition as a whole, and
- causation of an individual episode of it in a particular patient
will be described separately.
CAUSATION OF AN ACUTE EPISODE This is usually a readily understandable matter in clinical practice. The usual model of multifactorial causation applies, with predisposing, precipitating and perpetuating factors. Common situations would include:
- poor compliance with medication, e.g. because of side-effects
- drop out of follow up, e.g. following house move
- substance misuse, e.g. alcohol or illegal drugs
- accommodation problems
- relationship problems
- content with criminal justice system
In most cases, be precipitating cause will be obvious; attention to the symptoms will be important, but the immediate problem causing the worsening of symptoms needs also to be addressed.
CAUSATION OF SCHIZOPHRENIA AS A CONDITION As with the causation of an individual episode, many different factors contribute: genetic, environmental, psychological and social. This may be disappointing to some, considering the huge amount of research, which has gone into the question. However, a simple ěmagic bulletî theory is never going to be sufficient to account for the complexity of the condition and its causation.
It is not the case that mental disorders are different from physical disorders in being somewhat ěmessyî as regards causation. Consider, for example, tuberculosis; we know that the tubercle germ is required to produce the clinical condition of tuberculosis. We also know that other factors, for example, heredity and socioeconomic status, influence whether the bacilli go on to cause clinical tuberculosis.
CAUSATION OF SCHIZOPHRENIA: OVERALL MODEL Although there is no agreement about the details, there is a general view that a the condition may reflect a combination of some or all of the following
- genetic predisposition
- subtle damage to the brain, perhaps through viral infection before birth
- the condition then ělies dormantî in childhood (though prodromal signs such as clumsiness, developmental delay, behavioural or emotional difficulties may later be able to be recognised- albeit retrospectively)
- the condition ěcomes outî after puberty, in the context of the ěrewiringî or remodelling of the brain that is known to go on at that time
- especially if the person is subject to further pathogenic factors such as, for example, cannabis use.
ěIs schizophrenia the price that Homo sapiens pays for language?î Such fascinating speculations link the causation of schizophrenia with the evolutionary development of language, and the origins of cerebral dominance (left or right handedness); gender differences are also in the mix, with males tending to develop the condition earlier, and to have worse outlook. GENETICS There is no doubt that the condition has a genetic aspect. Twin studies provide some of the strongest evidence, especially those comparing identical twins, who have the same genes, entirely, with nonidentical twins, who share only 50% of their genetic material, and are no more alike than two siblings from different pregnancies. If one twin has schizophrenia, then about 50% of the co-twins also have schizophrenia if they are identical, but only about 10% if they are nonidentical. Three points follow:
- there must be a genetic component to the causation of schizophrenia, otherwise there is no way of explaining the differences in the ěconcordance ratesî between identical and nonidentical twins.
- however, the condition is not completely genetic, otherwise there would be 100% concordance between identical twins for the condition.
- therefore, environmental factors must also be important.
HUNTING THE GENE FOR SCHIZOPHRENIA The human genome project was trumpeted by its projectors, as the fundamental answer to unravelling the DNA, which would lead on to the discovery of the underlying biochemical abnormalities, which, they presumed, were responsible for otherwise mysterious condition such as schizophrenia. A new discipline of ě psychopharmacogeneticsî has even been suggested, whereby genes would in some way guide drug treatment. Unfortunately, like other reductionist movements in medicine, the so-called ěhuman genome projectî has not, even after the expenditure of enormous sums of money, led to major advances in understanding in medicine in general, let alone to practical advances for psychiatric patients. It has recently been decided that the answer is to sequence the entire human genome again, but this time in patients with schizophrenia; one hopes this will not be throwing good money after bad. GENETIC RISKS The overall figures are that a first-degree relative of a patient with schizophrenia has approximately a 10% chance of having the disease himself, as compared with approximately 1% in the general population. Second degree relatives have about a 3% risk. If both the parents have schizophrenia, then the risk in the children is about 50%. Even if children with a genetic risk of schizophrenia are reared away from their biological families, for example through adoption, there is not much reduction in their risk of getting the condition, confirming a genetic component to its aetiology. INHERITANCE PATTERNS Here again, the picture is complex and confusing. Established techniques of genetic mapping have demonstrated that the patterns of inheritance differ between affected families. In some family trees, it looks as though a single gene might be responsible, though not being expressed to full effect in every individual carrying it (so-called incomplete penetrance). In other pedigrees, however, the pattern is better fitted by smaller contributions from a number of different genes. So far, therefore, it has not been possible to pinpoint one particular gene on one particular chromosome, either with traditional genetic mapping techniques, or with more recent genome sequencing. BRAIN BIOCHEMISTRY Disturbance of the ěchemical balanceî in the brain is frequently suggested as part of the background to mental illness. In the case of schizophrenia, the introduction of effective antipsychotic drugs in the 1960s, starting with chlorpromazine, gave rise to neuro-chemical theories of causation. When the drugs were introduced, they were dramatically effective, and caused many long-term hospital inpatients to be able to be discharged. They were known to be effective antihistamine drugs, but the previous generation of antihistamines did not have their powerful antipsychotic properties. Studies were therefore done to see how these new drugs worked. It was found that they were probably working by an action on the substance dopamine, which is a naturally occurring neurotransmitter in the brain. ( A neurotransmitter is a chemical messenger, which is released in small packets at the surface of one nerve cell- the synapse- allowing it to communicate with its neighbouring nerve cells by interacting with receptors on it). For example, the potency of a drug per milligram, in blocking dopamine, was directly in proportion to its potency as an antipsychotic in clinical practice. The subtype of D2 dopamine receptors was particularly implicated. Unfortunately, as with genetics, the continuation of research has caused simplistic theories of ěexcessive D2 function = schizophreniaî to have to be abandoned as too simplistic. For example, clozapine is an extremely potent antipsychotic drug, but it only has weak D2 effects; this agent is powerful at 5HT2a receptors. Other neurotransmitters, for example GABA, ACh, serotonin and glutamate have also been implicated. It seems clear that dopamine is concerned in the process, but also that it is not the whole story. In line with this theory of how they work, was the observed side-effect of antipsychotic drugs to produce stiffness and shakiness of the muscles, similar to Parkinsonís disease, which is itself known to be caused by a lack of dopamine in certain parts of the brain (the substantia nigra of the basal ganglia). Other evidence supporting a role for dopamine includes the fact that drugs, such as amphetamines, which stimulate dopamine, can precipitate a schizophrenia-like condition (amphetamine psychosis). This point, it is somewhat vitiated however by the fact that such conditions can also be produced by other illicit drugs, including cannabis, and LSD, which affect different neurotransmitter systems. There have been studies showing changes in the number of dopamine receptors in the brains of patients with schizophrenia after death, but these are difficult to interpret because most of the patients will have received antipsychotic drugs, it is not possible to be absolutely sure that the changes in dopamine receptors are not due to the effects of the drugs. BRAIN STRUCTURE There are abnormalities, both on naked eye (macroscopic), and microscopic examination, and on special investigation with brain scans (CT and MRI). The brains of patients with schizophrenia tend to be smaller and lighter, and the normal fluid filled spaces inside the brain (the ventricles) are larger. In particular, the temporal lobes of the brain (which are near the temple, and control hearing) are smaller in schizophrenia; this establishes links with the possible source of auditory hallucinations, and ties in with the schizophrenia-like picture sometimes presented by patients who have temporal lobe epilepsy. These structural changes are thought to reflect abnormal brain development in early life, but degeneration at a later date might also contribute. In support of the importance of brain damage are clinical observations that schizophrenia is associated with:
- minor neurological signs (so-called ěsoft signsî)
- abnormalities on brain scan.
- Reduced to intellectual function, including IQ and poor performance on tests of memory, concentration and attention
- temporal lobe epilepsy of the dominant hemisphere
- birth complications- possibly involving mild brain damage due to lack of oxygen
- winter birth- possibly by means of an association with
- maternal viral infection in pregnancy
MICROSCOPIC EXAMINATION The neurones in this condition and to be smaller and less richly connected to their neighbours; this would tie in with theories about ěneuro-developmentî as part of the pathological process. PSYCHOLOGICAL ASPECTS Many theories have been put forward over the years, particularly driving from psychoanalysis; however, concepts such as the ěschizophrenogenic motherî are no longer regarded as helpful. In recent years, psychologists have used cognitive-behavioural models to try to understand and explain the psychotic phenomena seen in schizophrenia, for example, suggesting that delusions may have their origin in a person having an inbuilt tendency to jump to conclusions about things and to ignore conflicting evidence. (this has led on to the trial of CBT in psychosis, though there is no clear evidence at present that it is effective, and it has yet to establish a place in routine clinical practice). PERSONALITY In about 50% of patients, premorbid personality has ěschizoidî features such as social isolation and eccentricity, though this may represent a prodrome of the illness itself. Prospective cohort studies have shown that children who show such features have an increased risk of schizophrenia in later life. FAMILY AND SOCIAL FACTORS The work of RD Laing (The Divided Self) and many others, for example Batesonís ědouble bindî, focused attention on family dynamics and on the attitude of society as primary causes of schizophrenia. Looking back now, these seem to be more in the nature of cultural rather than scientific phenomena, coinciding as they did with the ěanti-psychiatryî movement and wider criticism of the Western nuclear family. The main survivor from these ideas has been the concept of ě expressed emotionî, where patients with schizophrenia who come from families who react strongly to their behaviours are known to be at increased risk of relapse. Family therapy can reduce the risk of relapse, though this result may not necessarily support the concept of ěexpressed emotionî, as the therapy could be operating in other ways. LIFE EVENTS As previously indicated, the occurrence of ělife eventsî frequently triggers an acute episode. This fact, although prosaic, it nevertheless, of great importance in the management of patients with this condition. CLINICAL FEATURES Clinically, schizophrenia is a highly heterogeneous condition. ONSET may be gradual and insidious, without obvious precipitating factors, or on the other hand, it may be acute, and seemed to be associated with life events. Symptoms may include abnormalities of perception, such as hallucinations, and abnormal beliefs, delusions. There may be disruption of thought processes, so-called thought disorder, plus behavioural and motor symptoms. I will now discuss the symptoms and signs of the condition, according to the standard headings of the mental state examination:APPEARANCE AND BEHAVIOUR The patient may present following contact with the criminal justice system, or after failure to cope in a first job or at university, or may withdraw into their house or room. Deliberate self harm and contact with drug and alcohol agencies are frequent. Often the standard of self-care, as reflected in the appearance, may be reduced. In severe cases, where the patient loses ability to care from themselves, there may be self-neglect. More frequently, the patientís appearance may be somewhat unusual, perhaps identifying himself as a member of a subculture. For example, wearing black clothes or having piercings, which might give rise to the supposition that they wish to be identified as a member of a ěgothî subculture, or flowery and flowing clothes, indicative of a ěhippyî image. By saying this, of course, I do not mean that there is anything intrinsically unhealthy about the adoption of particular styles of appearance; it is just that clinical experience indicates that fairly outlandish styles of dress are seen in newly presenting patients with schizophrenia. A misguided sense of ěpolitical correctnessî should not be permitted to lead one to ignore such matters. Tactful inquiry may therefore be necessary in order to find out their meaning to the patient. Presentations with abnormal movements, and fixed posturing (catatonia) are classical, though now in developed countries. They include mannerisms, stereotypies, imitation of the speech and behaviour of others (echolalia and echopraxia), negativism, mutism, stupor, hyperactivity, and prolonged maintenance of strange postures (waxy flexibility). SPEECH There is usually no abnormality in the production of speech itself. Mood Abnormalities of mood of some description or other are normally seen. Theses may be a flat or empty affect, especially in patients with an insidious onset and pronounced lack of will. There is not usually a pronounced and pervasive depression or elation of mood (if so, consideration of a primary mood disorder would be appropriate as an alternative diagnosis). MOOD may be incongruous, for example inexplicably cheerful, sometimes seeming to vary according to the content of auditory hallucinations. Extreme mood changes of elation, depression or rage may occur. Sustained depressive symptoms are found in at least 50% of patients on follow-up, and are probably part of the schizophrenic process, though they may also represent side-effects of antipsychotic drug treatment, or a response to realisation of having such a serious disease. THOUGHT: DISORDERS OF THE POSSESSION OF THOUGHT include thought insertion (a sensation that some outside agency is putting thoughts into oneís mind), thought withdrawal (the opposite experience) and thought broadcasting (the belief that oneís thoughts are being communicated to other people). Strictly speaking, these could be considered to be delusions, though often the experience is described in such a matter-of-fact way by the patient that it seems to be a phenomenon which is real to them. Thought block is the abrupt complete cessation of a train of thought THOUGHT: DISORDERS OF THE STREAM OF THOUGHT
- knightís move thinking (asyndetic thinking, derailment of thought) is abrupt transition from one topic to another unrelated one
- concrete thought is inability to appreciate abstract concepts, though some patients show the opposite tendency and assume symbolic meanings which are not intended
- poverty of thought is one of the ěnegativeî symptoms characteristic of the chronic stages of the illness.
Of course, our only way of knowing about the patientís thoughts is through their talk, which may be vague and difficult to follow. Sometimes, the patient will make sense in respect of individual sentences, but drift gradually off the point. They may seem to be articulate, and it may be some time before one appreciates that they are ětalking past the point,î or ětangentialî or ěoverinclusiveî.
There may be odd changes of topic, or be incomprehensibly bizarre. Some patients keep repeating the same words or phrases (verbigeration), use idiosyncratic words (neologisms), or, in very severe psychosis, speak in a jumble of words or even word fragments (word salad).
FALSE BELIEFS (DELUSIONS) The most common types of delusion in schizophrenia would probably be persecutory, but grandiose or nihilistic delusions are also common. As previously described, a delusion is a false (or usually false) belief which is unshakeable by reasoned argument, and which is inappropriate, bearing in mind the patientís cultural and religious background.
At this point, it is worth noting that, strictly speaking, paranoid has a wider meaning than just persecutory: the derivation, I understand, is from Greek words meaning ěout of mindî, and paranoid has been used to cover for example grandiose or sexual content of delusions also.
Delusions, I must add, are almost always false, though not always. Occasionally, they may be true- perhaps for example the police really are ěafterî the person. It is the reasons for the beliefs which are irrational, and fundamentally define the belief as delusional- for example, that patient knows the police are after him because they are wearing blue uniform.
Onset of schizophrenia may be preceded by delusional mood in which the patient feels perplexed because the environment seems subtly changed. This feeling may be suddenly followed by a primary delusion (autochthonous delusion), usually linked with an ordinary sense perception (delusional perception). For example, one patient saw a yellow car drive by and took this to mean that he was Christ reincarnated. Delusions are most often paranoid, but may be of any kind. A complex system of secondary delusions may be elaborated from the primary one.
HALLUCINATIONS These can affect any sensory modality, but most commonly hearing (auditory). Indeed, hallucinations affecting vision or smell would give rise to a suspicion that the patient might have an organic (physical), condition affecting the brain. Nevertheless, visual hallucinations and tactile hallucinations are seen in patients with very extreme schizophrenic states.
Detailed inquiry into the possible hallucinatory experiences are vital at a first presentation. It is all too easy for phenomena to be labelled as ěauditory hallucinations,î when in fact, they do not satisfy criteria for this. The problem is that if auditory hallucinations are recorded in medical notes, this can immediately give rise to a diagnosis of psychosis/schizophrenia, the patient can be placed on antipsychotic medication, and the symptoms and diagnosis repeated from year to year.
Patients in crisis may experience ěthe voice of conscience,î perhaps telling them: ěYou are a bad person.î Those with personality disorder may hear voices. ěTheyíre inside me ëead, doc, they keep telling me to cut meselfî. These are not true hallucinations, they are sometimes referred to as "pseudohallucinations."
In contrast, auditory hallucinations in schizophrenia are experienced as coming from the outside world. They are real to the patient. It is a real voice, but there is no one there speaking.
It is necessary to find out the patient explanation for this experience. Many patients, at least in the early stages, will find this completely terrifying. Other patients will regard it as ě part of the plan,î as it will be part of a system of delusions. Still others will, as time goes by, it used to the idea that the voices are not real, even though they were undoubtedly psychotic phenomena in the early years, and remain so.
Voices discussing the patient in the third person are characteristic but second person voices which talk to the patient are common too.
Volition: passivity feelings, in which emotions or actions are felt to be controlled by an outside agent, may be present. Bizarre urges out of keeping with the previous personality may occur. Some patients lack initiative and drive regarding activities of daily life.
COGNITION one of the original (Krapelinian) descriptions of the illness we now recognise as schizophrenia was as ědementia praecoxî, in other words, presenile dementia. The patient would display a gradual onset of symptoms, characterised by loss of initiative, lack of interest in self-care, and general social withdrawal; delusions and hallucinations, although often present, were not the dominant part of the clinical picture. Stereotyped behaviour was common.
These patients often ended up in long stay care in institutions, and undoubtedly would shown impairments on cognitive testing. However, such cases would be unusual in general psychiatric practice these days.
Regarding cognitive testing in patients with schizophrenia today, if they were in remission, it would be expected that ěbedsideî tests of orientation, concentration and memory would be roughly normal, though, if more subtle tests were done, it would be expected that they would underperform control subjects.
As regards patients with current acute psychosis, obviously, it would not be expected that they would be unimpaired in such tests. The key point to remember, however, is that in most cases of schizophrenia, there is no substantial cognitive impairment, and there is no ongoing process of cognitive deterioration such as would be seen in presenile dementia due to cerebral pathology such as Alzheimerís disease.
INSIGHT is the final heading in the mental state examinations as customarily set out. It is a fairly insignificant looking word, which belies its importance in management and prognosis. It would be better if the term was replaced by some such phrase as ěpatientís attitude to illness and treatmentî.
It is a complex matter, and essentially practical question such as
- ědoes the patient believe he is ill?î, and
- ěwill the patient accept treatment?î
are key; however, schizophrenic patients are often conflicted about the matter.
For example, sometimes they will only come into hospital against their will on a section of the Mental Health Act; nevertheless, once in the hospital, they do not try to leave and will seem to accept medication without dispute. Conversely, patients may say that they believe that they are ill, and that they will accept treatment when they leave the hospital; however, once out of the hospital, they refuse the treatment on the grounds that they do not believe that they are ill.
Accordingly, insight in schizophrenia is something which can only really be assessed on a trial and error basis, as it were, the proof of the pudding being in the eating.
POSITIVE AND NEGATIVE SYMPTOMS Symptoms of schizophrenia are sometimes divided into positive, such as delusions and hallucinations, and negative, such as poverty of thought and speech, lack of initiative, social withdrawal, slowness, unreliability and poor self-care. Positive symptoms are prominent during acute episodes, negative symptoms are characteristic of the chronic stage.
A more recent subdivision of symptoms describes three groups: reality distortion (that is, delusions and hallucinations), disorganisation (that is, disruption of the connection between thoughts, formal thought disorder) and psychomotor poverty (that is, negative symptoms). In effect, this system merely subdivides ěpositive symptoms,î into delusions and hallucinations on the one hand and formal thought disorder on the other; it has not achieved wide currency.
PHYSICAL HEALTH in patients with schizophrenia may be impaired because of heavy smoking, unusual eating habits, excess fluid consumption leading to water intoxication, poor hygiene, lack of exercise, other forms of self-neglect, and the side-effects of antipsychotic drugs (Ch 23) on various body systems.
METABOLIC PROBLEMS ěMetabolic syndromeî, so-called, is a combination of truncal obesity, abnormal blood lipids, disturbed insulin and glucose metabolism, and high blood pressure; it is associated with the development of diabetes mellitus and coronary heart disease. It is more frequent in patients with schizophrenia, than in the general population.
It may be particularly contributed to by antipsychotic medication, especially some of the newer ěatypicalî agents such as olanzepine, which seems to have particular appetite stimulating qualities.
Case Example A young woman of 21 developed beliefs that her computer games were communicating with her, by means of messages through the screen and that only she could see. Some of the messages were transmitted ědirectly into my mindî.
She had been an average student in her early teens, but her performance had declined and she had left school at 16, without qualifications. She had then attended a local college sporadically, but had dropped out, and seemed mainly to have been at home with her family.
Most of the time since then she seemed to have spent in her room, playing computer games for several hours per day; she also consumed a good deal of cannabis, which seemed to be regarded as normal in the home.
Admission to hospital followed a disturbance at home when she smashed up the television, and her room.
On admission she had delusions about being controlled by computer games; during admission, it became clear that she was subject to auditory hallucinations, but would never say anything about them.
She was tried on various medications, but was observed to deteriorate; she appeared to develop thought blocking so that it was impossible to have a conversation: she would volunteer no speech, and questions were answered, after a second or two pause, by an uncomprehending ěEh?î
She showed no response to standard medications (haloperidol) or to ěatypicalî medications (olanzepine); she was then tried on clozapine, which in conjunction with a rehabilitation placement, resulted in some symptomatic and functional improvement, so that she was able to be discharged eventually to supported- warden controlled- accommodation.
CLINICAL TYPES Much emphasis used to be placed on differentiating various subtypes of schizophrenia. It is important to be aware of the different terms. However they are of limited practical usefulness. They do not seem to predict response to medication, or overall prognosis.
Nor is it even clear that they are stable, through time, so that for example of patient may be displaying a picture of hebephrenic schizophrenia at one point but a picture of paranoid schizophrenia at another. Nevertheless, it is a matter of clinical experience that a patient does tend to have roughly similar patterns of symptoms and signs during each acute episode- the same behaviours or delusions or hallucinations recur.
The following summary, based on the ICD-10 classification, depends on the description of clinical syndromes. It is not known whether these represent truly distinct entities.
- Paranoid schizophrenia has delusions, often accompanied by hallucinations, as prominent symptoms.
Paranoid schizophrenia usually develops later in life than the other types, and schizophrenic illness starting after middle age nearly always takes this form. It is commoner in women, and in those with impaired hearing. Genetic factors seem less important than for other types of schizophrenia.
Contrary to what the public sometime seem to think, the term ěparanoid schizophreniaî does not mean the most serious or dangerous form of the illness.
- Hebephrenic schizophrenia Although the term is seldom used in UK clinical practice, it may be employed in adolescents and young adults who have a clinical picture in which thought disorder and affective (mood) changes are prominent.
- Catatonic schizophrenia: Catatonia was common in the ěclassicalî era of psychiatry, when such authors as Krapelin and Bleuler were writing; it was frequently seen in the old mental hospitals, and remains common in developing countries. This is now rare in UK practice: I have not seen a full-blown case for several years. But it is important to be aware of, because it may pose diagnostic and management difficulty if staff have not encountered it before.
The patientís clinical picture is like no other; he may appear cut off from the external world, even though he has apparently an undiminished level of consciousness. This can progress to catatonic stupor. Patients may also have varying degrees of abnormal movement, especially the adoption of abnormal postures for prolonged periods of time, for example, keeping an arm outstretched for many hours, which would be impossible for most people.
On examination, such a limb may exhibit the classical ěwaxy flexibility.î This means an increase in muscle tone, which is continuous and progressive as the limb is passively moved. This is qualitatively different from the increased tone is seen for example in upper motor neurone lesion such as stroke or parkinsonism.
The condition responds to medication and nursing care, but ECT may be necessary in emergencies.
- Simple schizophrenia (another term now seldom used) is characterised by negative symptoms, with gradual deterioration of the personality, flattening of affect, withdrawal from reality, and loss of drive, resulting in a lifestyle of social isolation and self-neglect. Positive symptoms may be few, so in some such cases it is debatable whether a diagnosis of schizophrenia is actually justified.
However, these can be amongst the most disabled patients with schizophrenia, with inability to function independently. Response to medication is often poor. They will clearly stand in need of mental health services such as supported accommodation. So the question of whether or not, a particular diagnosis is appropriate may be somewhat academic.
- Residual schizophrenia is again a term not frequently used in clinical practice. It refers to the ědefect stateî when delusions and hallucinations have passed, but when the patient remains affected by negative symptoms such as lack of initiative, apathy, self-neglect hands emotional blunting. Reduction of medication and rehabilitation may be appropriate. Clozapine should be considered.
- Schizotypal disorder is described in the ICD as ěA disorder characterized by eccentric behaviour and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies occur at any stage. The symptoms may include a cold or inappropriate affect; anhedonia; odd or eccentric behaviour; a tendency to social withdrawal; paranoid or bizarre ideas not amounting to true delusions; obsessive ruminations; thought disorder and perceptual disturbances; occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation. There is no definite onset and evolution and course are usually those of a personality disorder.î
Again, in my experience, this is not a diagnosis frequently used in clinical practice. The ICD say that it excludes ěschizoid personality disorderî, but does not give clear instructions as to how they are to be differentiated. In practice, patients with the characteristics described would probably be regarded as having mild schizophrenia.
- Delusional disorders There are conditions where the patient just has delusions, with few other symptoms. These will be dealt with in a separate chapter.
- Acute and transient psychotic disorders. Patients occasionally present having become acutely psychotic ěout of the blueî, with no previous history. Delusions and hallucinations, with disturbed behaviour, may be prominent, for a few days or so, and then completely resolve.
Sometimes there are obvious precipitants, such as emotional distress, overwork or physical illness. Some cases are never heard from again. Others go on to have further episodes.
Some psychiatrists doubt whether stress, in the absence of predisposition or illicit drugs or some other definite causative factor, is capable of causing true psychosis, however.
Because of the difficulty in assessing and in predicting further episodes, most psychiatrists would record a diagnosis of ěpsychotic episodeî after a first one, as the diagnosis of schizophrenia can be more upsetting for the patient, and can have worse consequences, for example for insurance and work.
- Schizo-affective psychosis, in which manic or depressive (affective) symptoms co-exist with schizophrenic ones, and the illness follows a course of relapses and remissions. The term often gives rise to confusion, however: sometimes it is used to refer to an episode where the patient has a mixture of mood and psychotic symptoms; at other times, it denotes a patient who has an episode of mood symptoms and then and episode of psychotic symptoms. Both types occur.
They would be assessed and treated according to the symptoms prominent at the time, but bearing in mind the overall temporal pattern of the disorder. If there were regular relapses with good recovery, this would resemble bipolar affective disorder; preventive treatment, for example with a mood stabiliser would be indicated even if the current symptoms were mainly psychotic.
If there are few other symptoms, and the general personality is well preserved, the condition may be called paraphrenia if it comes on in later life. This especially applies in older patients, often with social isolation (e.g. following being widowed) and deafness of other sensory impairments.
DIAGNOSTIC CRITERIA Present criteria are purely clinical and not fully satisfactory. Controversies about the diagnosis of schizophrenia include:
- Whether the term should be reserved for illnesses which result in permanent residual defects (nuclear or process schizophrenia) or also used for acute episodes (schizophreniform reactions) which may recover completely.
- Whether the different clinical types of ěschizophreniaî are variants of the same disease process, or separate conditions.
- Whether cases without positive symptoms should be included.
- Whether there is a valid distinction between schizophrenia and the affective psychoses.
When Kraeplin described the condition in 1896 under the name dementia praecox he distinguished it from manic-depressive illness because of its worse prognosis. E Bleuler, who coined the term ěschizophreniaî in 1911, considered the essential features were loosening of associations in thought, flattening or incongruity of affect, ambivalence and autism (withdrawal from reality) and some permanent defect in personality.
As these symptoms cannot be precisely defined, widely differing concepts of ěschizophreniaî developed in different centres; for example schizophrenia was diagnosed more readily in the USA, which followed the looser Bleulerian approach, than in the UK, which adopted a tighter Krapelinian view. The differences persisted until the later editions of the DSM, which came closer to the ICD view (see below).
In recent years there have been attempts to standardise the definition. A popular system in Britain is that of Schneiderís first rank symptoms. Schneider in the 1950s postulated a set of any one of which would be diagnostic of schizophrenia in a patient without organic brain disease. They are: - 2 or more hallucinatory voices discussing the patient in the third person
- voices making a running commentary on his thoughts or actions,
- voices repeating his thoughts aloud (echo de la pensČe).
- Thought insertion, or withdrawal
- Thought broadcasting
- Bodily (somatic) feelings of influence: the patient has bodily symptoms which he feels are produced by some outside agency
- Passivity feelings. the patient experiences his thoughts or actions as being controlled by some external agency
- Delusional perception- a normal perception gives rise to a fully-formed delusion, e.g. ěthe red car has just gone past, I am the Messiah.î
However, research has shown that Schneiderís symptoms may occur in affective psychoses also; they do not necessarily predict long-term outcome. Nevertheless, they remain a useful diagnostic pointer.
The main systems in use today are the DSM and the ICD. They are fairly similar (though widely different in the past). The main differences are in the duration required, ICD 1 month, DSM six months, in social or occupational dysfunction, which is required and the DSM but is not specified under ICD.
DIFFERENTIAL DIAGNOSIS The condition must be distinguished from:
- Organic brain disease, such as temporal lobe epilepsy, head injury, or any form of physical condition affecting the brain. HIV may produce similar pictures in developing countries.
- Drug-induced psychosis: Cannabis, LSD, amphetamines, cocaine, ěmagic mushroomsî, MDMA (ěecstasyî). This is a common diagnostic question- and management problem- in everyday clinical practice.
The drugs involved will vary from place to place and from time to time. In the UK, cannabis is the main culprit. Cannabis use is a frequent contributory cause of psychosis.
Stimulants such as amphetamine and cocaine can produce major psychotic states, often with persecutory delusions and disturbed behaviour including aggression.
- Affective psychosis: in other words, schizophrenia needs to be distinguished from depressive psychosis, and from manic states where there are delusions and hallucinations as part of the picture.
- Obsessive-compulsive disorder. In severe obsessional states, the behaviours and thoughts can almost take over the patientís life, and if they are of a bizarre nature may be difficult to distinguish from psychosis.
- Acute reactions to stress, especially in adolescents.
- Simulation of mental illness: rare.
Some of these conditions may present as indistinguishable from schizophrenia. The correct diagnosis can only be made after investigation of physical factors, and a period of observation, especially if the episode was triggered by drug misuse, and/or a trial of antipsychotic treatment.
TREATMENT
MEDICATION Antipsychotic drugs remain the mainstay of treatment. However, there has been a great change in prescribing over recent years in the UK. So that newer drugs, the so-called atypicals, have to a significant extent supplanted the original drugs such as chlorpromazine and haloperidol.
There has been great enthusiasm for the new drugs, which were promoted as having fewer side-effects, and therefore the more acceptable to patients and promoting better quality of life. They have undoubtedly been a success in commercial terms. However, as with any new drug, the adverse effects have taken a little time to come out, and we are now in a situation where the balance of risks and benefits of the new drugs as against the older drugs is becoming clearer.
Medication is effective in controlling positive symptoms in about 90% of acute cases. Oral administration is usually suitable, but severely disturbed patients may need intramuscular doses to start with.
If there are worries that the patient may not be swallowing tablets, then liquid preparations, or special tablets which dissolve quickly in the mouth (of olanzepine), can be helpful.
Medication may need to be given for up to four weeks before improvement starts to occur. If the patient requires sedation, the addition of a benzodiazepines such as lorazepam can be most helpful and will tend to assist in avoiding excessive doses of antipsychotic.
CHOICE OF DRUG NICE recommends that ě..a person who has been newly diagnosed with schizophrenia, doctors should consider prescribing one of the following atypical (newer) oral antipsychotic drugs: amisulpride, olanzepine, quetiapine, risperidone or zotepine.î This has become accepted practice, and many patients do recover on such a regime. However, there is less agreement as to what should be done if the patient does not respond to say risperidone or olanzepine.
Experience indicates that the most severely psychotic patients often do not respond, or do not respond fully, to the newer drugs. It should be borne in mind that, in modern randomised controlled trials of medication, the most severely affected patients are often excluded. This will be, for example, on the grounds that if a person is dangerously unwell, it would be wrong that they should be exposed to the risk of having a dummy (placebo) treatment.
If the patient is severely unwell, and has not responded to an atypical, then, one of the older drugs should be employed. In these cases, they appear stronger antipsychotic agents.
The prescriber would then face a choice between either stopping the atypical, and starting one of the ěclassicî medications, or adding in the second drug and continuing with the atypical. In my practice, a typical example would be a patient who has been started with olanzepine, and has benefited from the sedative and hypnotic properties of that drug, but still has troublesome delusions and hallucinations. I often see good results from adding in a small dose of haloperidol, say, 1.5 to 5 mg daily.
In this connection, it should be remembered these medications gained their poor reputation for side-effects from having been used in excessively high doses over the years. Haloperidol 1.5 mg is a powerful antipsychotic regime, and may be sufficient, for example in elderly patients. If very high doses of haloperidol are given however, side-effects will increase, whereas antipsychotic affects may not. Trials of atypical agents, compared with haloperidol have of course taken the opportunity to use large doses of haloperidol, thereby helping to demonstrate greater acceptability to patients of the new agents.
Many patients do very well on small doses of haloperidol or trifluoperazine, and do not experience side effects from them, and NICE does not recommend any change in these circumstances. CLOZAPINE NICE is very positive about the use of this drug in treatment resistant schizophrenia: ěIn individuals with evidence of treatment-resistant schizophrenia (TRS), clozapine should be introduced at the earliest opportunity. TRS is suggested by a lack of satisfactory clinical improvement despite the sequential use of the recommended doses for 6 to 8 weeks of at least two antipsychotics, at least one of which should be an atypical.î The disadvantages of this include the fact that it can cause bone marrow suppression, and therefore frequent monitoring of blood tests is required; even with careful monitoring, occasional deaths occur. It can only be given by mouth, and often causes hypersalivation. However, most practising clinicians would agree that these are outweighed by the advantages, which are that it can produce improvements when other medications have failed to do so. It is very rewarding for all concerned when a patient who has been severely unwell in the hospital can after clozapine treatment experience symptomatic and functional improvement and be able to be discharged. However the drug is seldom curative; if it does work, the effect can take weeks or months to build up, and residual symptoms and impairments continue. Nevertheless, it can offer dramatic improvements in symptoms and quality of life. SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS The older drugs cause extrapyramidal side-effects commonly, particularly increases in muscle tone (stiffness), and tremor; risperidone and the other in atypicals can also caused these, but less frequently. The main problem with the atypical medications has been weight gain, and olanzepine seems to be notable for this; it seems to have an appetite stimulating effect, and cases of diabetes have also been recorded. There is also a risk of stroke in elderly patients with Alzheimerís, so that risperidone and olanzepine are now contra-indicated for this indication. By extension, they would probably be best avoided in all elderly patients, and possibly also in all those with cerebral vascular risk factors of whatever age. MAINTENANCE TREATMENT Patients who have made a good recovery from a first episode of schizophrenia may be able to taper off their medication after a few months. Those who have persistent symptoms, or frequent relapses, are usually kept on medication long-term. However, long-term therapy carries a higher risk of side-effects, so it needs to be monitored carefully, and the dose kept at the minimum necessary for symptom control.
Patients who have done well on small doses of medication can be considered for a trial of seeing if they can do without it completely. However, this will depend on what the patient wants; some patients who have been very unwell in the past, rightly fear the return of symptoms and prefer to carry on with medication long-term. If however, they wish to see if they can do without medication, they will require close monitoring during the trial period; it will be necessary to restart the medication straight away if symptoms re-emerge.
In general, patients who have a clear history of schizophrenia and who are doing well on a small dose of medication, which is not causing side-effects, are probably best advised to stay on it indefinitely unless they have strong wishes to the contrary.
DEPOT MEDICATION This refers to long-acting preparations of antipsychotic medication, so that a patient who, for whatever reason, does not take tablets regularly, can instead be offered an injection of antipsychotic medication every 2, 3 or even 4 weeks. The active drug is suspended in a tiny quantity of oil, from which it is gradually released through time. This form of treatment serves to keep a large number of patients reasonably well.
Frequently, it is a somewhat paradoxical situation, with the patient not fully believing that they are unwell, and not being keen on taking tablets: they nevertheless turn up for their injection every fortnight and stay reasonably well as a result.
Since it has to be given by intramuscular depot injections, it also ensures that patients are seen regularly by a community nurse or GP.
OTHER DRUGS Many patients with pronounced mood instability or depression-or more commonly flatness-of mood are prescribed mood stabilisers or antidepressants respectively. If the question arises, there it is often a strong case for at least trying the effect of such medications; response is unpredictable. Even if there is no benefit, at least the practitioner will have tried, and will therefore have been seen to have listened to the patient and/or his family and/or his care co-ordinator. This cannot but be helpful to the building up of a therapeutic relationship.
PSYCHIATRIC SERVICES The key to the patient remaining well is to have a good and continuing relationship with his psychiatrist, and his care co-ordinator, who will usually be either a community psychiatric nurse or a social worker.
There has recently been a good deal of development in services. Assertive Outreach Teams have been developed in community mental health services; these are concerned with patients who disengage with treatment, and they can be effective in reducing hospital admission and improving the lives of some of these severely affected patients.
CRISIS TEAMS are designed to step in emergencies and provide extra help according to the results of a joint assessment with the community mental health team, and other parties. They can be helpful in reducing hospital admissions; however, it is important that inpatient admission is not seen as a failure, let alone as a bad thing. On the contrary, hospital admission frequently achieves progress, even when the best efforts of community services have not.
Another development has been the introduction of Early Intervention Teams; these are intended to identify and treat only or even prodromal cases; the idea is that by doing so, the ove
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