Schizophrenia

An overview of schizophrenia

For centuries schizophrenia has been considered the psychiatric disease par excellence, due to its conspicuous expressions (if not properly treated) and the impossibility of interacting with the persons affected, and making them “reason” according to conventional criteria. People suffering from schizophrenia, in fact, perceive reality in an altered way – and respond accordingly, with behaviors and actions that are difficult to understand for others.

Typical of schizophrenia is, in particular, the presence of delusions/fixations, hallucinations, disorganized thinking and speech, and non-purposeful movements.

Schizophrenia is a chronic disorder that, today, can be kept under control with effective therapies (to be taken constantly, throughout one’s life), but is not yet curable. Generally, after its onset, the disease tends to progressively aggravate more or less slowly, depending on the individual case and on the precocity and adequacy of the treatments administered. Typically, schizophrenia first occurs in adolescence or early adulthood, rarely in children or after age 45. Its onset tends to occur earlier in males and somewhat later in females, in whom it is most often diagnosed around the age of 25-30.

Symptoms and diagnosis of schizophrenia

A diagnosis of schizophrenia requires a psychiatric examination and a comprehensive medical evaluation, in order to understand its symptoms.

The diagnosis of schizophrenia is a very sensitive matter, both for the frequent overlap of its manifestations with those of other psychiatric diseases (in particular, bipolar disorder in the manic phase, borderline personality disorder, “agitated” depression, etc.) – or with decidedly extravagant but not pathological adolescent behaviors – and for the implications that a diagnosis of this type has for the person concerned, from a medical, family, professional and social perspective.

For this reason, before hypothesizing the presence of schizophrenia, it will be necessary to exclude other psychiatric disorders (for which effective therapies, characterized by a more favorable prognosis, may be available), as well as physical diseases with psychiatric/behavioral repercussions, and it should be verified that the symptoms encountered have not been induced by drugs used for the treatment of other conditions, or by the intake of illegal substances (in particular those with stimulating/excitatory action, such as cocaine, amphetamines, etc.).

To form a correct clinical picture, a specialist psychiatric visit and a global medical evaluation, the collection of personal and family medical history, and the execution of several laboratory tests (blood and urine) are always necessary, with the addition, in some cases, of instrumental investigations (CT scans or brain MRIs).

Given these premises – and according to the updated version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) – a person can be diagnosed with schizophrenia when, for a period of at least one month, at least two pivotal symptoms of the disease are present for most of the time, including:

• delusions/fixations;
• hallucinations;
• disorganized thinking (and speech);
• disorganized or abnormal movements;
• catatonic attitude;
• negative symptoms.

At least one of the symptoms should relate to the presence of delusions/fixations or hallucinations or disorganized thinking (and speech). In addition, for a period of at least six months, some degree of mental impairment/distress should be present, and the subjects should show a marked decline in their school or work activities, or in the performance of routine daily occupations that previously did not involve any trouble.

The previous edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), in use until 2013, provided for a subclassification of schizophrenic pictures also according to the predominant manifestations, namely “paranoid”, “disorganized”, “catatonic”, “undifferentiated” and “residual”. In the updated, currently valid version (DSM-V), these specifications have been removed: on the one hand, because in many cases they were attributed incorrectly; on the other, because they lacked any real utility for the treatment and prognosis of patients.

Typical symptoms of schizophrenia

Delusions/fixations. Thoughts and beliefs that have no evidence in reality, but that are perceived/experienced as absolutely plausible and truthful (for example, the belief that someone wants to harm us, or speaks ill of us behind our backs, the conviction to be extraordinarily intelligent and gifted, or famous, or that a person is in love with us, or to have a serious illness not recognized by doctors or that our body is not working as it should, that a catastrophe is about to occur, etc.). Delusions and fixations affect about 80% of people with schizophrenia.

Hallucinations. In many cases, people with schizophrenia see non-existent things or hear words/phrases that no one has actually spoken. Although entirely unreal, hallucinations are believed to be absolutely true by the person experiencing them. The most frequent hallucinations concern “voices”, but altered perceptions – that is, not corresponding to the external reality – can concern any area of ​​sensitivity (sight, touch, taste, hearing, smell).

Disorganized thinking (and speech). Typical of schizophrenia, the impairment of complex thinking leads to a corresponding difficulty in formulating meaningful sentences and in expressing logical reasoning. This can prevent people from communicating effectively with the person affected, who can mix up words or, for example, answer questions in an unrelated or rambling way.

Disorganized or abnormal movements. People suffering from schizophrenia tend to have disorganized movements, and make non-purposeful and unpredictable gestures, mostly uncontrollable (motor agitation). This can make it very difficult to perform the most common daily activities, thus creating problems for family members and caregivers. Typical of these symptoms are the inappropriate and extravagant postures, the absence of motor response to stimuli – or to the requests to perform a certain action – and the presence of ineffective or exasperated movements.

Negative symptoms. For the outsider observer, agitation and extravagant behaviors are often the most impactful manifestations. In reality, in people suffering from schizophrenia the main concern should be mainly caused by the negative symptoms, such as: the absence of emotions, apathy, a lack of interaction with the interlocutor, a fixed facial expression, a monotonous and inflection-free speech, the absence of movements associated with communication, and the loss of interest in oneself and in the external events. All these symptoms lead, in fact, to a lower chance of recovery with the rehabilitation strategies, and to a worse prognosis of the disease (more significant cognitive and global decline).

In adolescents, the symptoms of schizophrenia are similar to those of adults, but more difficult to recognize, since they can overlap – at least in part – with the typical behaviors of this age group, always quite problematic in terms of relationship/interaction. Some signs that should prompt parents and teachers to pay particular attention to the psychological health of the adolescent include isolation from friends and family not motivated by specific situations, a significant and unexpected decline in school performance, the onset of sleep disorders, the presence of depressed mood or irritability (both persistent or inconsistent), and a lack of motivation and pleasure in carrying out the activities typical of this phase of life. Furthermore, compared to adults, young people with schizophrenia tend to have less frequent delusions/fixations, and more often visual hallucinations.

Regardless of age, people with schizophrenia tend to have recurring suicidal thoughts and to adopt self-harming behaviors (cuts, scrapes, bruises and injuries of various kinds). This aspect must be taken into consideration by doctors and family members/caregivers, both when the person concerned is at home and during any hospitalizations. Other possible complications of the disease include: the onset of anxiety/phobias or depression; alcoholism or substance abuse; health problems related to the side effects of the drugs used to control the symptoms of the disorder, or resulting from an inadequate lifestyle (excessive smoking, inappropriate diet, sedentary lifestyle, etc.); social isolation; aggressive/violent behaviors (very uncommon, if drug treatment has been well set).

Discover the causes of schizophrenia

Causes and risk factors of schizophrenia

The genetic and environmental nature of the risk factors for schizophrenia is uncertain.

Schizophrenia is never an isolated disorder. Generally, it affects multiple members of the same family, in successive generations, which suggests that the causes of the disease are at least partly genetic in nature, even if the identity of the genes involved is not yet known. Equally uncertain is the nature of the environmental factors that certainly contribute, to a more or less significant extent, to fuel the disorder. In some cases, a viral origin has been hypothesized; in others, the exposure to particular substances present in the environment; but there is no definitive scientific evidence in this regard.

Regardless of the specific trigger, the neurological damage alters the functioning of the dopaminergic system, that is, the brain circuit made up of neurons that use dopamine to communicate. In particular, it has been observed that, in schizophrenic patients, the dopaminergic system works more than in the general population, and this hyperactivity induces a clinical picture very similar to that found following intoxication with narcotic substances, such as cocaine or amphetamines.

Studies with imaging techniques such as CT, magnetic resonance (MRI) and PET have shown that in people with schizophrenia there is also an alteration of the brain structures and of the metabolism of the neurons in the so-called “frontal lobes”, i.e. the areas of the brain responsible for the executive functions and the organization of complex activities and planning. This means, for example, that if the person with schizophrenia sees a dirty floor, they recognize that that floor needs to be cleaned, but cannot mentally order the necessary actions to do so and, after a few minutes, they do not even remember that they had or wanted to clean it.

Risk factors for schizophrenia

• A family history of schizophrenia (siblings, parents, uncles, grandparents, cousins, etc.)
• Exposition to viruses, toxic substances or malnutrition during fetal development, particularly in the first and second trimester of pregnancy
• Presenting a significant and persistent activation of the immune system, as in the case of chronic inflammatory conditions or autoimmune diseases
• Being born to an elderly father (at the time of conception)
• Having taken drugs or exciting/psychotropic substances during adolescence or in the early years of adult life.

Treatment of schizophrenia

Schizophrenia is a complex chronic disease that, at present, can be managed almost exclusively in terms of symptom control and slowing of functional decline. The obtainable results vary from patient to patient, depending on the characteristics of the disease in each single case and the individual response to the proposed treatments. In general, however, the outcomes of pharmacological interventions, psychotherapeutic support and rehabilitation are better when the diagnosis is early.

Pharmacological therapy

The setting of a long-term drug therapy is always essential in the case of schizophrenia.

Psychological support and rehabilitation

In most cases, once the patient is stabilized, drug therapy is also accompanied by psychological support interventions (individual, family or group) and/or a cognitive-behavioral rehabilitation therapy aimed at re-training the patient to perform organized and finalized sequential operations. In practice, in the rehabilitation sessions, the patient is confronted with a typical everyday practical problem, and is helped to develop a project – namely, a mental and operational pathway – which allows them to solve it. The “practical problem” to be addressed can be washing dishes, preparing a cake or making an object with clay. With these activities, we try to “train” or reactivate the nervous circuits that tend to remain or become inactive due to the disease. More recently introduced rehabilitation strategies also exploit the potential of virtual reality.

Tips for family members and caregivers

Schizophrenia is a challenging disease for both the persons directly affected and for their family members. To be able to manage it in the best way, and to maintain a positive attitude despite any daily difficulties, it is important to:

• inquire about the characteristics of the disease, the therapies available to keep it under control and the benefits they can offer, in order to motivate the patient to take the necessary drugs every day;
• attend psychological support groups, to share any difficulty, doubt and experience endured while living with a person affected by schizophrenia;
• focus the attention on specific short-term goals, being aware that schizophrenia is a developmental disease, which should be managed day by day;
• use relaxation and stress management techniques – such as meditation, yoga, or tai chi – to ease the tension associated with constant confrontation with the disease;
• try to carve out spaces dedicated to self-rewarding activities, that allow caregivers to temporarily distract themselves from the burden of managing the person with schizophrenia;
• learn to recognize the situations of excessive fatigue and stress, and to allow for vacation periods, during which to entrust the patient’s care to others.