MENTAL HEALTH
Schizophrenia: difficult to define, diagnose and treat
Posted Tue, 30 May 2000

Schizophrenia is possibly one of the most misunderstood of all psychiatric illnesses. It is difficult to define, difficult to identify and difficult to treat. All this is surprising when you consider that it is actually one of the more common mental illnesses, with a lifetime prevalence of about 1% across all cultures. In the USA there are approximately 2 million people with the illness. Most schizophrenics become ill in their most economically productive years, with resultant lost productivity which is serious for any economy.

What is this illness, how can it be treated and will we ever be able to prevent it?

What is schizophrenia?

Schizophrenia is an illness characterised by psychosis. Psychosis is defined as a severe mental derangement involving the whole personality. In practice this means people who present with bizarre behaviour in which they believe things which have no basis in reality. For example they may believe that the radio is broadcasting their thoughts, or that external voices are telling them to behave in a specific way (auditory hallucinations), or that they are some famous person from history (delusions).

Schizophrenics lose touch with reality, undergoing a complete disorganisation of their personalities which makes it difficult for them to function normally; to maintain relationships, hold down jobs and interact within society.

Diagnosing schizophrenia

Psychosis is found in other problems and a single episode does not necessarily mean a diagnosis of schizophrenia. Psychotic symptoms can occur in some medical and neurological conditions, with alcohol or drug abuse, in depressive illness, and in certain personality disorders.

For someone to be diagnosed as schizophrenic they must have characteristic symptoms for more than 6 months, and show a marked deterioration from a previous level of functioning in areas such as work, social relations and self-care.

There are four recognised types of schizophrenic disorder:

• Catatonic which is relatively rare in which the patient is unresponsive, adopting either a rigid or bizarre posture, or showing marked excitement.

• Disorganized, characterised by incoherence and a flat or totally inappropriate appearance.

• Paranoid which is a type featuring suspicion and delusions (thoughts which have no basis in reality).

• Undifferentiated, where delusions, hallucinations, incoherence and disorganized behaviour is prominent.

What causes schizophrenia?

As with so many other medical problems, no-one is really sure. It seems to be a combination of genetic and environmental factors. There is some recent evidence to suggest that there is an association between schizophrenia and changes on chromosomes 6 and 8. However, the link is far from confirmed. Media interest in genetics and schizophrenia has led to a number of common misconceptions about the illness and its causes. Some of these, along with the correct information, are outlined.

Common misconceptions about schizophrenia

• Schizophrenia is caused by a single gene. Unlikely. In most cases multiple genes will be responsible.

• A gene for schizophrenia has been identified. This is simply not true. There are some regions of the genome which look promising, but no specific gene or neurochemical defect has been identified.

• Environment is not important. Environmental factors are important in the development of schizophrenia, but no specific trigger has been identified.

• Genetic testing is available for schizophrenia. No specific gene has been identified, so this is not true. In fact it is unlikely that this will ever be the case since it is likely that there are multiple genes involved in schizophrenia.

• Social factors cause schizophrenia. There is no evidence to suggest that social factors will cause schizophrenia in someone who is not genetically predisposed to the illness.

• If schizophrenics do not have children, the population incidence of the illness will decrease. There is no clear relationship between genetic and non-genetic causes of schizophrenia, so it is impossible to predict with any accuracy who will get the illness. Psychiatrically normal people may carry genes predisposing to schizophrenia. At present experts believe that an individual has to inherit multiple predisposing factors and be in a sufficiently unfavourable environment to develop schizophrenia. So, schizophrenia will not decrease in the population if people with the illness do not have children.

• It will soon be possible to screen for schizophrenia. There is no sign of this, either prenatally, presymptomatically or on a population level.

All this is telling us is that we are still not sure what causes schizophrenia and we are not yet in a position to prevent the illness.

Suicide and schizophrenia

As many as one in 4 persons with schizophrenia commit suicide, some even when they are under regular psychiatric care. It is most common among people between the ages of 30 and 40. They are generally people with a fairly high level of functioning, a history of prior suicide attempts, and is more common among those with the paranoid form of the disease.

The total personality breakdown which occurs with schizophrenia results in feelings of hopelessness and despair which may well lead to suicide, and drug treatment must target depressive features if present as well as psychosis.

Treatment

Anti-psychotic drugs are the first line of treatment in schizophrenia, with little role for counselling and therapy in the acute stage of the illness. This may be helpful once the psychotic symptoms are under control, when the patient needs support and help in understanding their illness.

In the acute phase drugs such as Largactil® (chlorpromazine) and Serenace® (haloperidol) are often used. Maintenance is generally with so-called depot preparations such as Modecate® (fluphenazine) which can be injected monthly.

Anti-psychotic drugs have many side effects. These include Parkinsonian syndrome, in which the patient appears to have the symptoms of Parkinson's disease, movement disorders such as inability to sit still and acute dystonic reaction with facial grimacing and abnormal neck and tongue movements. Consequently people on these drugs must be monitored reguarly and maintained on as low a dose as possible.

Between one-fifth and one-third of schizophrenic patients do not respond adequately to drugs. These people often have distressing symptoms and need long periods in hospital. There are newer anti-psychotics available now, such as Leponex® (clozapine)and Risperdal® (risperidone), and these tend to be reserved for those who do not respond to conventional treatment. Leponex must be used with care since it may cause serious blood problems.