Schizophrenia

Schizophrenia is a mental disorder characterised by disruption in thoughts, emotions, behaviour, reality testing, and cognitive functioning causing significant distress to the person or decline in the capacity to function.

The disruption in thoughts can present through speech as muddled thinking, the mind going blank, or mixing unrelated topics in a way that is difficult to follow. In extreme cases, thoughts can be completely illogical and incomprehensible. Sometimes a person with schizophrenia can have inappropriate emotional reactions to situations, like being completely indifferent and untouched by different events or may have inappropriate reaction like smiling and being happy when told sad news, and vice versa.

In terms of the behaviour, this can be a disorganised behaviour or bizarre, like being mute, posturing, repeating actions and phrases of others automatically, etc.

Impaired reality testing can manifest with delusions (inappropriately fixed beliefs held despite evidence to the contrary) or hallucinations (a perception without a real stimulus). An example of a delusion would be paranoid delusions of people being after the person without a real reason behind this. Delusions can be in many themes, including guilt, grandiosity, poverty, etc. Hallucinations can be in any of the five senses (visual, auditory, olfactory, gustatory and tactile (taste, smell and touch). Hallucinations and delusions are usually referred to as the positive symptoms of schizophrenia. On the other hand, the deficit-like presentation is usually referred to as the negative symptoms and usually presents with slowed thought process, slowed movement, lacking initiative and lacking interest in participating in any activities (without being depressed).

The diagnosis of schizophrenia is usually based on clinical assessment by a doctor (GP or psychiatrist) after excluding any possible medical conditions which could present in a similar way to schizophrenia, e.g. delirium or direct effect of drugs like steroids, amphetamines and others. Once all these possibilities are excluded, the diagnosis can be made if the person fulfils the Diagnostic and Statistical Manual V (DSM) criteria (or other classification systems like ICD-10) which are:

A Two or more of the following lasting for a month:

1. Delusions
2. Hallucinations
3. Disorganised speech
4. Disorganised behaviour
5. Negative symptoms

B Significant impairment in functioning

C Six months duration of disturbance to include one month of symptoms from group A and any disturbance from usual self for the remaining of the six months which can include mild form of the symptoms of schizophrenia¹.

Schizophrenia is usually the result of the interaction between genetics and environmental factors². A family history of schizophrenia can increase the vulnerability to developing schizophrenia later on in life, particularly if the person has several environmental factors involved starting from foetal development (stress or infection in the pregnant mother), at birth (trauma or hypoxia), early childhood adversity (abuse or parental separation), illicit drug use³ (particularly heavy use starting from a young age), or social stressors later on in life (migration⁴ or urban living⁵). Sometimes, schizophrenia can happen without any obvious reasons.

The cornerstone of treatment for schizophrenia is antipsychotic medication, usually combined with psychological and social interventions.

Medications:
Antipsychotic medications are usually recommended as part of the treatment of psychosis to assist in recovery and prevent further relapse. There are a number of antipsychotic medications available and choice needs to be personalized to ensure the best tolerability and efficacy. Where possible, the strategy should be to start the antipsychotic at a low dose and gradually in-crease to minimize any side effects.

Benzodiazepines are often useful as short-term addition to the antipsychotic medication during an acute episode since they reduce agitation, tension and anxiety and help with sleep. However, care should be taken to avoid using them for more than 4 weeks due it their addictive nature.

Antipsychotic medications can be taken orally or given as a depot (long-acting injection).

There are two groups of antipsychotic medications:
1. Typical or First Generation Antipsychotics (Australia):

2. Atypical or Second Generation Antipsychotics (Australia)

All antipsychotics are effective in reducing or eliminating positive symptoms of psychotic disorders; however, the atypical or second generation antipsychotics generally have less tendency to cause movement disorder side effects (“extrapyramidal side effects = EPSE) such as rigidity, persistent muscle spasm, tremors and restlessness. Furthermore, they may be effective in improving mood, thinking and motivation.

Antipsychotic medications help to restore the brain’s natural chemical balance, especially dopamine; hence, reducing or eliminating the psychotic symptoms.

How long will the antipsychotic medications take to work?
Antipsychotic medications begin to relieve agitation and sleep disturbances in about one week. Many people see substantial improvement by the fourth to sixth week of treatment. Do not decrease or increase the dose or stop the antipsychotic medication without discussing with your doctor first.

Why it is so important to keep taking them?
Antipsychotic medications reduce the risk of future psychotic episodes in people who have recovered from an acute psychotic episode. Even with continued drug treatment, some people who have recovered will suffer relapses. Because relapse of schizophrenia is more likely when antipsychotic medications are discontinued or taken irregularly, it is very important that people with schizophrenia work with their doctors and family members to adhere to their treatment plan.

Good adherence involves taking prescribed antipsychotic medication at the correct dose and proper times each day, attending clinic appointments, and/or carefully following other treatment procedures. Treatment adherence is often difficult for people with schizophrenia, but it can be made easier with the help of several strategies and can lead to improved quality of life.

How long should I take this medication?
Following a first episode of psychosis, it is recommended that antipsychotic medication can be continued for at least 1 -2 years; this decreases the chance of becoming ill again.

For individuals that have had a psychotic illness for several years or repeated psychotic episodes, antipsychotic medication should be continued indefinitely. This is similar to someone with diabetes requiring lifelong insulin.
What happens if a dose is missed?

Take the missed dose as soon as possible, as long as it is only a few hours after the usual time. Otherwise, wait until the next dose is due and take it as normal.

Antipsychotic medications, like virtually all medicines, have un-wanted side-effects along with their beneficial effects. It is important to remember that not everyone will have the same unwanted side-effects. Side-effects such as drowsiness, restlessness, muscle spasms, tremor, dry mouth or blur vision, usually occur early in the treatment, many of them will settle down after a few weeks, when the body has adapted to the medications.

The long-term side-effects of antipsychotic medications such as tardive dyskinesia (a disorder characterised by involuntary movements most often affecting the mouth, lips, and tongue, and sometimes the trunk or other parts of the body such as arms and legs. It occurs in about 15 to 20 percent of individuals who have been receiving the older, “typical or first generation” antipsychotic medications for many years.

‘Atypical or second generation” antipsychotic medications all appear to have a much lower risk of producing tardive dyskinesia (TD) than the older, traditional antipsychotics. However, they can produce side-effects of their own such as weight gain, which may place individuals treated with antipsychotics at risk of metabolic side-effects (“metabolic syndromes”). It is recommended that metabolic monitoring should be carried out regularly to all individuals who are taking psychotropic medications.

Cigarette smoking can change the amount of antipsychotic that remains in your bloodstream, especially clozapine, olanzapine, haloperidol. Inform your doctor if you make any changes to your current smoking habit.

Source: St Vincent’s Psychiatric medication information: A guide for patients & carers 4th Edition, 2017.

Electroconvulsive therapy (ECT) is a procedure where electric currents are directed to the brain. ECT treatments can provide a fast and considerable reduction of symptoms for people with severe depression as well as other mental health conditions, which can include:

– bipolar disorder
– schizophrenia
– catatonia

ECT is not typically recommended as the first option of treatment. It is prescribed when medications do not work, or when an individual cannot take medications due to the severity of side effects or another medical condition. It can be recommended when a person requires rapid treatment because they are at risk of suicide.

Cognitive Behavioural Therapy:
Structured time limited psychotherapy involving the here and now focusing on strategies to cope with the chronic and treatment resistant delusions and hallucinations.

Family therapy:
Family intervention to help the family to understand more about the illness and how best to support the family member with schizophrenia without adding more stress on the family as a unit and the individual with schizophrenia.

Others:
cognitive remediation therapy, supportive therapy, etc.

Social interventions include:
– Social skills training
– Vocational training
– Social support

Managing schizophrenia usually involves a team of different disciplines (i.e., a multidisciplinary team) to provide a holistic approach to the care and support while ensuring community follow up and monitoring of mental state. At times, the illness can take a severe form with total loss of reality testing, self-harm, suicidal thoughts or even thoughts of harming others. In such cases, admissions can be necessary and in rare cases, electroconvulsive therapy may be considered.

Almost half (42%) of the people with schizophrenia will have a good long term outcome , a further 35% will have an intermediate outcome and only 27% will have a poor outcome.⁶ Most people with schizophrenia are living in the community independently with community support.⁷