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Psychosis is a condition that affects the mind and brain function. Someone suffering from psychosis could experience some loss of contact with reality. Psychosis is most likely to occur in young adults. Majority of cases of psychosis have onset between the ages of 20 and 30. Males have a three to five year earlier age of onset compared to females. Psychosis, like any other medical illness, can be treated. In fact, many make a good recovery from psychosis with early identification and treatment.
There are different types of psychosis. It is not always apparent which type of psychosis one might be suffering from in the first encounter with a medical professional. Arriving at a diagnosis relies on the understanding of the etiology, duration and progression of the signs and symptoms, etc. of the psychotic episode.
Early psychosis refers to the early stages in which someone experiences psychotic symptoms. It is usually preceded by a period of vague psychotic symptoms (prodrome). A person with first-episode psychosis may have difficulty in understanding the experience as the symptoms can be confusing, distressing, unnerving and unfamiliar.
Schizophrenia is a more notable psychotic disorder that affects about 1% of the population. It is a kind of brain disease with symptoms that include hallucinations, delusions, disorganised 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. In this article, we shall take a closer look at 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, behaviour and emotion. This disease happens in 1% of the population. The majority of onset is between the ages of 20 and 30.
Like many other complex physical 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%” suggests 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.
There are 2 major groups of symptoms, namely “positive symptoms” and “negative symptoms” of schizophrenia.
The “positive symptoms” include delusion, hallucination, disorganised 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 that does not exist in reality.
The “negative symptoms” pertain to blunting of emotion, lack of volition, and poverty in thought. The patient also has impairments in cognitive function, e.g. attention, judgment and memory. With all these disturbances, the patient has decline in social and vocational functioning.
Because the brain is the most complex organ in the body, scientists have not yet fully 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 that 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 release 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, when we see a man is holding a knife towards us, the dopamine activities in our brain gives a sense of “personal significance” to this man; therefore, we have the correct belief that he is harming us. 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 makes 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 the street to be searching him particularly (i.e. a delusion). The abnormality of dopamine released in his brain made him so convinced 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).
Treatments of schizophrenia include medication, psychological treatment and rehabilitation training.
With the advance of neuroscience, there are medications which can effectively rectify some of the disturbed chemical activities 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 that can be very threatening and distressing to them.
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; the muscle power can be preserved through appropriate stretching and weight bearing exercise.
Psychiatric rehabilitation training allows the patient to regain the skills that are important for interacting with people in daily lives and at 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. 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 suffer a relapse. While it is understandable that family members might be frustrated by the negative symptoms of the patient (e.g. lacking volition in self care), criticism and hostility bring no improvement at all. Instead, they create 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 provides the family with information about the illness to reduce blame on the patients and family guilt.
Much more research is needed to fully understand how antipsychotic agents work to relieve the positive symptoms of schizophrenia. Most antipsychotics work by inhibiting the excessive dopamine activities in the brain so that no more “abnormal personal significance” is being attached to things around the patient (i.e. no more new delusion developed). After taking antipsychotics, the patient will not immediately get rid of the delusion he has been holding, but he will become less preoccupied on such belief and have less distress. He will then become more open to other explanations to the events he encounters. For example, “I always come across with policemen on the streets because there are policemen on patrol every day”; “they are not looking for me, because they have never approached me even after numerous encounters in the public”.
The first generation antipsychotics have the major side effects of Parkinsonian features, e.g. shaky hand, rigid limbs and slowness in movement. Over the past two decades, the advance of neuroscience leads to the availability of the second generation of antipsychotics which result in much fewer Parkinsonian side effects. Nonetheless, they have relatively more side effects in risks of metabolic syndrome (including high blood sugar, blood lipid and blood pressure, and increased body weight). These risks can be modified by maintaining a healthy lifestyle, e.g. physical exercise and diet control. Every medicine has therapeutic effects and 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 to their doctor so that their doctor can adjust the medications to minimise the side effects. It is unwise to refuse any medication treatment for fear of side effects. It is because even if there are side effects, the doctor always has the option of adjusting the dosage, changing to another medication or stopping medications.
Antipsychotic medications are very effective in relieving the positive symptoms of schizophrenia. However, unlike antibiotics that 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. They attempt to normalise the disturbed chemical activities in the brain as far as possible, like how antihypertensive medication moderates the activity of the degenerated blood vessels and the heart.
Therefore, there is a much higher risk of relapse after stopping the antipsychotics. In most cases, doctors recommend the patient to continue the medication after recovering from an episode in order to consolidate the recovery and minimise the risk of a relapse.
The illness of schizophrenia dispossesses a person’s control on his mind. The antipsychotics would not control the patient’s mind; instead, the medicines function as a tool to restore the brain activities back to normal and helps the patient to regain the control of their mind. In contrast, illicit drugs, e.g. ketamine, amphetamine, damage a person’s mind and subsequently control the person’s mind.
(Special thanks to Dr William Chui and Dr Stanley Yip of Institute of Mental Health, Castle Peak Hospital, for authoring this article)
The Royal College of Psychiatrists
