10. Schizophrenia


by National Foundation for Brain Research

Schizophrenia is a severe mental disorder, affecting approximately one in a hundred people at some stage during their lives. The most prominent symptoms are hallucinations and delusions (see below). Schizophrenia is known for its bad prognosis. Amongst others, the International Pilot Study of Schizophrenia (coordinated by the World Health Organization) has shown that the prevalence of schizophrenia is similar in many cultures. The notion of a "group of schizophrenias", coined by the Swiss psychiatrist Eugen Bleuler points to the early idea that there may be subtypes of the same disease, that may not even have the same etiology. These subtypes manifest themselves in very different ways . That makes the disease sometimes hard to diagnose. Often the definite diagnosis is preceded by milder or vaguer diagnoses like "psychotic process", "identity problems", "severe depression", "personality disorder" etc. Not until the patient is overtly psychotic and in a bad state the diagnosis is made, often with the adjective "possible". This shows the cautiousness with which the diagnosis is made. Often this longitudinal view is required to make the diagnosis confidently. The advent of the modern classification systems has improved the reliability of the diagnosis.

Clinical features
The characteristic symptoms (which typically start between the age of 18 and 30) are hallucinations and/or delusions, or what is called the "negative syndrome". Hallucinations can have various modes: most common are the auditory hallucinations: the hearing of voices (mostly inside the head) talking to the patients. Sometimes more than one voice talk to each other about the patient. Mostly the remarks are pejorative or insulting (you are no good, you are the devil, etc). Hearing voices is not just characterisctic of schizophrenia. It is also seen in dissociative, affective and organic states. Visual hallucinations are less common. Some object or person who is not there is definitely perceived as present in the presence of a clear consciousness. Tactile hallucinations are the least common. Examples are the experience of being touched by someone or that something is creeping underneath the skin.
Delusions are false or irrational beliefs that are firmly held despite obvious evidence to the contrary. Most common are persecutory, grandiose and religious delusions. This includes the experience of being given a special talent by some alien force or being followed by the CIA, who try to kill the patient. Grandiose delusions can also be seen in some manic patients, who lack the bizarre quality that often accompanies schizophrenia. Bizarre delusions are those that can obviously not be true("I came to Earth on a star", "my liver is made out of gold"). Often some alien force or power comes into play.
Other characteristic symptoms are those pertaining to the thinking process. Patients may feel that their thoughts are under control of someone else, or that thoughts are actually put into (thought insertion) or taken out of their heads (thought withdrawal). These symptoms are called first rank symptoms, thought to be typical of schizophrenia.
The negative syndrome is a change in behaviour, characterized by social withdrawal, self-neglect, blunted affect and speech disorders like poverty of (content of) speech. Social functioning is often impaired (occupational and social disabilities) in people suffering from schizophrenia. They often find it very hard to get or keep a job and are not quite up to the exigiencies that society requires. A steady relationship with a partner is beyond the grasp of many of the afflicted.

Diagnostic classification
As stated in the introduction the diagnosis is not always easy to make. Though current classification systems are by and large in concord about the criteria, these criteria have changed substantially over time. From the four A's of Bleuler (Ambivalence, loosening of Associations, Autism, blunted Affect) to DSM-III-R and ICD-10 many classification systems have seen the light of day. The changing criteria have implications for epidemiology. Today's criteria are more stringent than those of some decades ago. This may lead to lower incidence and prevalence rates in community or case register studies, leading in its turn to the impression that these rates are decreasing, whereas the case-finding technique itself has changed.
The dramatically different forms the disease can take, raise the question whether the subtypes (see below) are part of the the same disease process and share the same aetiology. This caused a researcher to say that trying to define schizophrenia is like aiming at a moving target. She is probably right.
The fact that some of the prominent but complicated symptoms (thought withdrawal/insertion) are sometimes misdiagnosed adds to the problem. Structured clinical interviews (like SCAN and CIDI), providing the queries tapping the symptom, but also the descriptions of the symptoms can improve the interview technique of the clinician or researcher.

The modern classification systems (the Diagnostic and Statistical Manual and the International Classification of Diseases) discern four subtypes:

  1. The simple or undifferentiated type of schizophrenic manifests an insidious and gradual reduction in his external relations and interests. His emotions lack depth, his ideation is simple and refers to concrete things, and there is a relative absence of mental activity, a progressive lessening in the use of inner resources, and a retreat to simpler or stereotyped forms of behaviour.
  2. The hebephrenic or disorganized type of schizophrenic displays shallow and inappropriate emotional responses, foolish or bizarre behaviour, false beliefs (delusions), and false perceptions (hallucinations).
  3. The catatonic type is characterized by striking motor behaviour. The patient may remain in a state of almost complete immobility, often assuming statuesque positions. Mutism (inability to talk), extreme compliance, and absence of almost all voluntary actions are also common. This state of inactivity is at times preceded or interrupted by episodes of excessive motor activity and excitement, generally of an impulsive, unpredictable kind.
  4. The paranoid type is characterized primarily by delusions of persecution and/or grandeur often accompanied by hallucinations.

The cause of schizophrenia is not definitely known. Hereditary aspects certainly are a factor of importance, as twin-studies have shown. First degree relatives have a higher risk of acquiring the disorder. The notion that rearing styles or upbringing causes shizophrenia has been entirely abandoned. Though causes per se are not known, those afflicted by the disease are thought to have a congenital vulnerability for decompensating under stressful circumstances. Indeed, stress may precipitate the first onset of the psychosis or cause a relapse.

Results of various studies have shown a great diversity in course. Very roughly one could say that a third of the patients will recover completely, without a residual state. Another third will be afflicted by psychosis in several episodes during their lives. In between these episodes most patients suffer from some residual symptoms. A last third will suffer from psychotic symptoms throughout their lives, not in phases. They often require permanent hospitalisation. There are indications that the severity of the psychosis is leveling off later in life. Prognosis has improved with the advent of neuroleptic drugs in the 50's.

Curing the disorder is not within the grasp of medicine as yet. Though symptoms like hallucinations and delusions can be successfully (though not always) treated with neuroleptic drugs, the basic process is thought to be active throughout life, mostly in phases. The side-effects of these drugs, like trembling, sweating, impotence and Parkinsonism cause distress in many patients. Some newer, atypical neuroleptics (like Risperidone, Olanzapine and Clozapine) do not have these extrapyramidal effects, but the latter warrants close monitoring because of the risk of agranulacytosis. Treatment, apart from medication, often consists of teaching coping mechanisms on how to deal with stressfull events and how to live with the handicap. The patient is informed about the nature of his disease and about its consequences (psycho-education).