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Mental Health Tips > Schizophrenia and other psychotic disorders

Schizophrenia and other psychotic disorders
(Special thanks to Dr William Chui of Institute of Mental Health, Castle Peak Hospital, for authoring this article)

Schizophrenia and other psychotic disorders are a kind of brain diseases. They affect about 1% of the population. The main symptoms include hallucination, delusion, disorganized speech and behaviour; these symptoms are accompanied by significant decline in social and occupational functioning. Abnormal transmission of chemicals, including dopamine, in the brain causes the symptoms in schizophrenia. Antipsychotic medications are effective in relieving the symptoms of schizophrenia by restoring the normal activities of neurons. Psychological treatment and rehabilitation training are also important treatments. Treatment at the early stage of illness is crucial in the recovery, and therefore patients should seek psychiatric assessment and treatment early.

 
1. What is schizophrenia?
2. What are the causes of schizophrenia?
3. What are the main symptoms of schizophrenia?
4. How does neuronal dysfunction lead to the symptoms in schizophrenia?
5. What are the treatments of schizophrenia?
6. How do medications relieve the positive symptoms?
7. What are the side effects of antipsychotics?
8. Why not stop the antipsychotic when the patient is mentally stable?
9. Does antipsychotic medication control the patient’s mind?



1. What is schizophrenia?

A psychotic disorder, most notably schizophrenia, is a kind of brain disease. Disturbance in functioning of different neurons manifests mainly as disturbance of thinking and perception, which commonly lead to marked change in speech, behavioural and emotion. This disease happens in 1% of the population. The onset is mostly during 20 to 30 years old.

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2. What are the causes of schizophrenia?

Like many other complex diseases, e.g. diabetes and cancer, individual vulnerability and environmental stressors interact and contribute to the onset of schizophrenia and other psychotic disorders.

In schizophrenia, genetic predisposition plays the most important role in vulnerability. Unlike the heritance of ABO blood group which involves one single gene, schizophrenia involves numerous genes. Many of us have probably inherited, by random, some vulnerability genes of schizophrenia from our parents who are not showing symptoms of schizophrenia. The number is so small that it does not confer enough vulnerability to have the disease surfacing out. Therefore, even though a couple has no symptoms of schizophrenia, their children still have a disease risk of 1%. For a person born from parents who both suffer from schizophrenia, this risk is about 30%, i.e. still 70% chance of having no schizophrenia.

Nonetheless, schizophrenia is not completely a genetic disease. For a pair of identical twins, if one of them suffers from schizophrenia, the chance for the other one suffers from schizophrenia is only 50%. If schizophrenia was purely hereditary, both members of a pair of twins must be schizophrenic, leaving no chance of only one having this disease. Therefore, this “50%” suggest that although there is an important genetic factor, there must be also an environmental factor contributing to the onset of schizophrenia.

When stressful events, such as being abused in childhood, failed romance in adolescence, burden from school, workplace and family, accumulate beyond a certain level, the brain with the genetic vulnerability cannot cope with stress. Eventually, the stress leads to the onset of illness. Environment stressors also include the toxic effect of illicit drug (e.g. cannabis) to the brain.

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3. What are the main symptoms of schizophrenia?

There are 2 major groups of symptoms, namely “positive symptoms” and “negative symptoms” of schizophrenia.

The “positive symptoms” include delusion, hallucination, disorganized speech and behaviour. A delusion is a disturbance in thinking. A delusion is a firmly held belief which is false and out of keeping with the patient’s social and cultural background. Hallucination is a disturbance in perception. The person hears (the most common), smell, feel or see something which does not exist in reality.

The “negative symptoms” pertain to blunting of emotion, lack of volition, poverty in thought. The patient also has impairments in cognitive function, e.g. attention and memory. With all these disturbances, the patient has decline in social and vocational functioning.

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4. How does neuronal dysfunction lead to the symptoms in schizophrenia?

Because the brain is the most complex organ in the body, scientists has not yet completely understood how the dysfunction in brain leads to all the symptoms in schizophrenia. So far, we have more understanding on the positive symptoms of schizophrenia which involves the dysfunction of a chemical, called dopamine, in the brain.

In the brain, dopamine is one important chemical which allows our brain to give us the sense of “personal significance” and “drive” to something in the environment. To survive in an environment, the nerves in our brain releases dopamine as appropriately as possible, so that we can reason something to have a personal meaning only when there is some objective evidence. For example, I see that now a man is holding a knife towards me, the dopamine activities in my brain gives a sense of “personal significance” to this man; therefore, I have the correct belief that he is harming me. This belief is driven by what really happened in the environment.

However, when dopamine is being excessively and inappropriately released in the brain, the inappropriately released dopamine made a person has a wrong sense of personal significance towards things in the environment. For example, a person will consider every policeman on routine duty of parole in street to be searching him particularly (i.e. a delusion). The abnormality of dopamine release in his brain made him so convicted on such belief that he is not subject to rational explanation and is behaving in reaction to this belief (e.g. dare not to leave home at all).

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5. What are the treatments of schizophrenia?

Treatment of schizophrenia includes medication , psychological treatment and rehabilitation training.

With the advance of neuroscience, there are medications which can effectively normalize some of the disturbed chemical activity in the brain and thereby much relieve the symptoms, mainly positive symptoms of schizophrenia. Psychological treatment also helps the patients to cope with the symptoms who can be otherwise very threatening and distressing to the patient.

Negative symptoms are mainly managed by psychiatric rehabilitation training, e.g. social skill training, and supported employment. Receiving rehabilitation training at early stage of schizophrenia is crucial in preserving the motivation to activities and work ability. Psychiatric rehabilitation training is like physiotherapy for an injury to limbs; by appropriate stretching and weight bearing exercise, the muscle power is preserved.

Psychiatric rehabilitation training allows the patient to regain the skills important for interacting with people in daily living and workplace. Engaging the patient in a job appropriate to his ability helps to maintain motivation to job and to master the skills. Employment is effective in boosting the self-esteem of patients with schizophrenia.

Family intervention is also an important treatment for schizophrenia. As psychological stress is an important factor in the onset and subsequent relapse of schizophrenia. There is strong evidence showing that when family members are hostile, critical or emotionally over-involved towards the patient, he is more likely to have a relapse. While it is understandable that family members might be frustrated by the negative symptoms of the patients (e.g. lacking volition in self care), criticism and hostility brings no improvement at all. Instead, it creates stress to the patient and precipitates relapse of the illness.

In family intervention, the therapist helps the family to explore the current problems and coping strategies for each of them, encourages respect and communication within the family, and provide the family with information about illness to reduce blame on the patients and family guilt.

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6. How do medications relieve the positive symptoms?

Much more research is needed to fully understand how antipsychotic agents work to relieve the positive symptoms of schizophrenia. Most antipsychotic works by inhibiting the excessive dopamine activities in the brain so that no more “abnormal personal significance” is being attached to things around the person (i.e. no more new delusion developed). After taking antipsychotics, the person will not immediately get rid of the delusion he has been holding, but he will be become less preoccupied on such belief and have less distress. He then starts to be able to take other explanations for what he happens to him. For example, “I always come across policemen in street because there are policeman on patrol every day in public areas”. “They are not looking for me, because they do not come to arrest me after numerous encounters in public”.

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7. What are the side effects of antipsychotics?

The first generation antipsychotics have the major side effect of Parkinsonian features, e.g. shaky hand, rigid limbs, slowness in movement. Over the past two decades, the advance of neuroscience leads to the availability of the second generation of antipsychotics which has much less Parkinsonian side effects. Nonetheless, they have relatively more side effects in risks of metabolic syndrome (high blood sugar, blood lipid and blood pressure, increased body weight). These risks can be modified by healthy life style, e.g. physical exercise and diet control. Every medicine has the therapeutic effects and the side effects. A medicine is used on a patient when the therapeutic benefit outweighs the harms of side effects. Side effects differ very widely among individuals. Patients should report the problems they have to their doctor who can adjust the medications to minimize the side effects. It is unwise to refuse any medication treatment for fear of side-effect. It is because even if side effects are experienced by the patient, the doctor always has the option of adjusting the dosage, changing to another medication or stopping medications.

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8. Why not stop the antipsychotic when the patient is mentally stable?

Antipsychotic medications are very effective in relieving the positive symptoms of schizophrenia. However, unlike antibiotics which can cure an episode of infection, antipsychotic medications do not cure schizophrenia. They cannot fundamentally correct the underlying the structure in the diseased brain cells. It attempts to normalize the disturbed chemical activities in brain as far as possible, like how antihypertensive medication moderates on the activity of the degenerated blood vessels and heart.

Therefore, there is a much higher risk of relapse after stopping the antipsychotic. In most cases, doctors recommend the patient to continue the medication after recovering from an episode in order to consolidate the recovery and minimize the risk of a relapse.

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9. Does antipsychotic medication control the patient’s mind?

The illness of schizophrenia dispossesses a person’s control on his mind. The antipsychotic would not control the patient’s mind; instead, the medicine functions as a tool which restores the normal activities of brain and helps the patient to get back control on their mind. In contrast, illicit drugs, e.g. ketamine, amphetamine, damage a person’s mind and subsequently control the person’s mind.

Websites with relevant information / Reference

The Royal College of Psychiatrists

Kapur, S. 2003. Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. Am J Psychiatry, 160, 13-23.

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